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Individual

MRS. KRISTIN NOELLE WILSON

Active
Sole proprietor

Provider details

NPI number
Gender
F
Credential
OTR/L

Contact information

Practice address
1760 N WOODLAND AVE, FAYETTEVILLE, AR 72703-2549
(479) 443-4420
Mailing address
3525 HAMM LN, SPRINGDALE, AR 72762-0765
(479) 756-0051

Taxonomy

Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
OTR 1316
AR

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
5U124
ARBCBS
AR
01
NBCOT 1024062
NAATIONAL O.T. PROVIDER #
01
OTR 1316
STATE LICENSE #
AR
Enumeration date
05/01/2006
Last updated
07/09/2007
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