Provider Demographics
NPI:1124151527
Name:KATHY LAOMA WILSON
Entity type:Organization
Organization Name:KATHY LAOMA WILSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:LAOMA
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-996-2770
Mailing Address - Street 1:104 C WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:DONIPHAN
Mailing Address - State:MO
Mailing Address - Zip Code:63935-1780
Mailing Address - Country:US
Mailing Address - Phone:573-996-2770
Mailing Address - Fax:573-996-4233
Practice Address - Street 1:104 C WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935-1780
Practice Address - Country:US
Practice Address - Phone:573-996-2770
Practice Address - Fax:573-996-4233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0008057Medicaid