Provider Demographics
NPI:1346379443
Name:WILSON, KATHRYN MARLENE (CRNA)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:MARLENE
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KAY
Other - Middle Name:MARLENE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 82144
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99708-2144
Mailing Address - Country:US
Mailing Address - Phone:907-479-7017
Mailing Address - Fax:
Practice Address - Street 1:1275 SADLER WAY
Practice Address - Street 2:STE 202
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-452-4101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK34367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered