Provider Demographics
NPI:1861936346
Name:WILSON, KATHLEEN MARIE (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2336 S RIM DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81507-1432
Mailing Address - Country:US
Mailing Address - Phone:970-216-5795
Mailing Address - Fax:855-820-1836
Practice Address - Street 1:2754 COMPASS DR STE 377
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8723
Practice Address - Country:US
Practice Address - Phone:970-257-2384
Practice Address - Fax:970-257-2401
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0992757-NP363LG0600X
COAPN-0992757-NP363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology