Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0401X | Family Doctor - Addiction Medicine | 71001728A | IN |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 3004516 | KY |
N | 363LF0000X | Nurse Practitioner - Family Medicine | 4516P | KY |
N | 363LF0000X | Nurse Practitioner - Family Medicine | 71001728A | IN |
NPI | 1417984758 |
---|---|
Provider Name | Mrs. Denise Blair Wilburn |
First Address | Charlestown, IN 47111-9535 |
Second Address | Jeffersonville, IN 47130-6016 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2006 |
Last Update Date | 08/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1105450 | RN LICENSE (01) | KY |
3004516 | LICENSE NUMBER (01) | KY |
4526P | ARNP LICENSE (01) | KY |
71001728A | LICENSE NUMBER (01) | IN |
K156040 | MEDICARE PTAN (01) | KY |