Healthcare Provider Details

I. General information

NPI: 1700859386
Provider Name (Legal Business Name): MELINDA DILLARD WILSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2631 TEMPLE AVE N
FAYETTE AL
35555-1157
US

IV. Provider business mailing address

128 ALLYN TRCE
WINFIELD AL
35594-6261
US

V. Phone/Fax

Practice location:
  • Phone: 800-648-3271
  • Fax: 205-932-2153
Mailing address:
  • Phone: 205-487-7080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number037
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: