Basic Information
| Provider Information | |||||||||
| NPI: | 1811947583 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKENS | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | DIANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN- CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 12752 KINGSTON PIKE | ||||||||
| Address2: | STE E202 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379340948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657770909 | ||||||||
| FaxNumber: | 8657770910 | ||||||||
| Practice Location | |||||||||
| Address1: | 18797 ALBERTA STREET | ||||||||
| Address2: | |||||||||
| City: | ONEIDA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378412127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657770909 | ||||||||
| FaxNumber: | 8657770910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN1108135 ARNP4723A | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 11198 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 4723A | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 87629 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0000001218303 | 01 | KY | CHA HEALTH | OTHER | P00695348 | 01 | TN | RAILROAD MEDICARE PIN | OTHER | 000000382181 | 01 | KY | ANTHEM BCBS KY | OTHER | 000000382181 | 01 | KY | UNICARE | OTHER | 74002270 | 05 | KY | MEDICAID | P00309974 | 01 | KY | RAILROAD MEDICARE PIN | OTHER | 000000382181 | 01 | KY | KENTUCKY ACCESS | OTHER | 3630866 | 05 | TN | MEDICAID | 4126702 | 01 | TN | BLUE CROSS/BLUE SHIELD | OTHER | 000000382181 | 01 | KY | BLUE CROSS/BLUE SHIELD | OTHER |