Provider Demographics
NPI:1366877805
Name:WILSON, KANDACE D (RN, BSN)
Entity type:Individual
Prefix:
First Name:KANDACE
Middle Name:D
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 W NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-3642
Mailing Address - Country:US
Mailing Address - Phone:920-203-6440
Mailing Address - Fax:
Practice Address - Street 1:910 W NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-3642
Practice Address - Country:US
Practice Address - Phone:920-203-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI146589-30163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health