Provider Demographics
NPI:1588778997
Name:WILBURN, KANDA
Entity type:Individual
Prefix:
First Name:KANDA
Middle Name:
Last Name:WILBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 PRESTON ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-4028
Mailing Address - Country:US
Mailing Address - Phone:870-532-2600
Mailing Address - Fax:
Practice Address - Street 1:1510 BYRUM RD
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-8033
Practice Address - Country:US
Practice Address - Phone:870-532-2600
Practice Address - Fax:870-532-9484
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2267235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y555Medicare UPIN