Provider Demographics
NPI:1104611920
Name:WILSON, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WILSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 PIEDMONT DR STE 2005
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-4175
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 PIEDMONT DR STE 2005
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-4175
Practice Address - Country:US
Practice Address - Phone:434-710-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL006913133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered