Provider Demographics
NPI:1770551319
Name:WILSON, TINA L (ARNP RN)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:ARNP RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2609
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-2609
Mailing Address - Country:US
Mailing Address - Phone:270-769-1601
Mailing Address - Fax:270-765-7274
Practice Address - Street 1:580 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2949
Practice Address - Country:US
Practice Address - Phone:270-765-6196
Practice Address - Fax:270-763-0397
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1072465163W00000X
KY2609P363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
S98316Medicare UPIN