Provider Demographics
NPI:1679728026
Name:WILSON, KATHLEEN P (PHD,CPNP, FNP-BC)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:P
Last Name:WILSON
Suffix:
Gender:
Credentials:PHD,CPNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FSU HEALTH LIFESTYLE MEDICINE CLINIC
Mailing Address - Street 2:1630 RIGGINS ROAD
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308
Mailing Address - Country:US
Mailing Address - Phone:850-878-4434
Mailing Address - Fax:949-655-8526
Practice Address - Street 1:FSU HEALTH LIFESTYLE MEDICINE CLINIC
Practice Address - Street 2:1630 RIGGINS ROAD
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-878-4434
Practice Address - Fax:949-655-8526
Is Sole Proprietor?:No
Enumeration Date:2008-11-27
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1018702363LP0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH27639Medicare UPIN