1396862223 NPI number — MS. KRISTI JO WILSON F.N.P. - B.C

Table of content: MS. KRISTI JO WILSON F.N.P. - B.C (NPI 1396862223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396862223 NPI number — MS. KRISTI JO WILSON F.N.P. - B.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
KRISTI
Provider Middle Name:
JO
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
F.N.P. - B.C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GEORGE
Provider Other First Name:
KRISTI
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-BC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1396862223
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8293 OFFICE PARK DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND BLANC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-694-3576
Provider Business Mailing Address Fax Number:
810-760-0440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8293 OFFICE PARK DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND BLANC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-694-3576
Provider Business Practice Location Address Fax Number:
810-235-2721
Provider Enumeration Date:
03/24/2007

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: 363LF0000X , with the licence number:  4704162286 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4762420 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0B51149 . This is a "BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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