Provider Demographics
NPI:1346128675
Name:WILSON, KIMBERLY ANTIONETTTE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANTIONETTTE
Last Name:WILSON
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 1:14407 WHITCOMB
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-2206
Mailing Address - Country:US
Mailing Address - Phone:248-470-9142
Mailing Address - Fax:
Practice Address - Street 1:14407 WHITCOMB
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2206
Practice Address - Country:US
Practice Address - Phone:248-470-9142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker