Provider Demographics
NPI:1457191561
Name:WILSON, KATELYN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
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:PO BOX 959794
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-9794
Mailing Address - Country:US
Mailing Address - Phone:501-364-1100
Mailing Address - Fax:501-978-6436
Practice Address - Street 1:2601 GENE GEORGE BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0845
Practice Address - Country:US
Practice Address - Phone:479-725-6800
Practice Address - Fax:479-725-6582
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR148802367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered