1326286089 NPI number — ANITA JANE WILKERSON CRNP

Table of content: ANITA JANE WILKERSON CRNP (NPI 1326286089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326286089 NPI number — ANITA JANE WILKERSON CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILKERSON
Provider First Name:
ANITA
Provider Middle Name:
JANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELLOGG
Provider Other First Name:
ANITA
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326286089
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 358
Provider Second Line Business Mailing Address:
JUNCTION OF HIGHWAY 371 & ROUTE 9
Provider Business Mailing Address City Name:
CROWNPOINT
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87313-0358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-786-5291
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
JUNCTION OF HIGHWAY 371 & ROUTE 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROWNPOINT
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
97313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-786-5291
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/03/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  R175091 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: R175091 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)