Provider Demographics
NPI:1861727273
Name:WILSON, KATIE LYNN (LPN)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 DEWEY PL SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44710-1614
Mailing Address - Country:US
Mailing Address - Phone:330-280-0510
Mailing Address - Fax:
Practice Address - Street 1:3216 DEWEY PL SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44710-1614
Practice Address - Country:US
Practice Address - Phone:330-280-0510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-03
Last Update Date:2009-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.119459 IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse