Basic Information
| Provider Information | |||||||||
| NPI: | 1588778997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILBURN | ||||||||
| FirstName: | KANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1904 PRESTON ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638574028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705322600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1510 BYRUM RD | ||||||||
| Address2: | |||||||||
| City: | BLYTHEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723158033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705322600 | ||||||||
| FaxNumber: | 8705329484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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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 | 235Z00000X | 2267 | AR | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.