Provider Demographics
NPI:1588484927
Name:WILSON, KATELYN MICHELLE (NP)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:MICHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 REMICK BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9168
Mailing Address - Country:US
Mailing Address - Phone:937-885-0701
Mailing Address - Fax:
Practice Address - Street 1:70 REMICK BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-9168
Practice Address - Country:US
Practice Address - Phone:937-885-0701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-11
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH459403163W00000X
OH0037888363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse