MEDICARE: MS. CHANDA WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	2023075	MN

General Provider Information

NPI Number	:	1235825969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHANDA WILSON

Provider Business Mailing Address
First Line	:	2091 SILVER BELL RD APT 46
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-1045
Country	:	US
Telephone Number	:	612-223-3449
Fax Number	:

Provider Business Practice Location Address
First Line	:	2091 SILVER BELL RD APT 46
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-1045
Country	:	US
Telephone Number	:	612-223-3449
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2023
Last Update Date	:	04/14/2023

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Directions to “ MS. CHANDA WILSON ” Practice Location

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