MEDICARE: MRS. REBEL FLYNN WILSON P.T.

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	225100000X	Physical Therapist	PT 2506	AR

General Provider Information

NPI Number	:	1295792315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REBEL FLYNN WILSON P.T.

Provider Business Mailing Address
First Line	:	710 FOXWOOD DR
Second Line	:
City	:	JACKSONVILLE
State	:	AR
Zip	:	72076-2642
Country	:	US
Telephone Number	:	501-985-0118
Fax Number	:

Provider Business Practice Location Address
First Line	:	5912 CYPRESS CREEK DR
Second Line	:
City	:	N LITTLE ROCK
State	:	AR
Zip	:	72116-6355
Country	:	US
Telephone Number	:	501-771-2005
Fax Number	:	501-771-2005

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

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	07/08/2007

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