Basic Information
| Provider Information | |||||||||
| NPI: | 1265671598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILEY | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99371 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828854054 | ||||||||
| FaxNumber: | 6828857497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2009 | ||||||||
| LastUpdateDate: | 03/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 670259 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200892204 | 01 | TX | CSHCN | OTHER | 081095 | 01 | TX | CRNA | OTHER | 200892203 | 05 | TX | MEDICAID |