Provider Demographics
NPI:1134617335
Name:WILSON, KELSEY ROSE (DO)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ROSE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 ASHLEY AVE. ROOM 202
Mailing Address - Street 2:MAIN HOSPITAL MSC 333
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-8905
Mailing Address - Country:US
Mailing Address - Phone:843-792-3451
Mailing Address - Fax:
Practice Address - Street 1:169 ASHLEY AVE. ROOM 202
Practice Address - Street 2:MAIN HOSPITAL MSC 333
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-9125
Practice Address - Country:US
Practice Address - Phone:843-792-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC52002207Q00000X
SCDO52002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program