Basic Information
| Provider Information | |||||||||
| NPI: | 1851747596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2011 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978502511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419634139 | ||||||||
| FaxNumber: | 5414296612 | ||||||||
| Practice Location | |||||||||
| Address1: | 2011 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978502511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419634139 | ||||||||
| FaxNumber: | 5414296612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2016 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | CNP-02899 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 202000961NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.