Provider Demographics
NPI:1538451141
Name:WILSON, KIMBERLY ROSE (ANP-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROSE
Last Name:WILSON
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6348 N MILWAUKEE AVE STE 390
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-3728
Mailing Address - Country:US
Mailing Address - Phone:847-235-6130
Mailing Address - Fax:847-235-6135
Practice Address - Street 1:6348 N MILWAUKEE AVE STE 390
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-3728
Practice Address - Country:US
Practice Address - Phone:847-235-6130
Practice Address - Fax:847-235-6135
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-15
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277000495363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health