Healthcare Provider Details

I. General information

NPI: 1699892612
Provider Name (Legal Business Name): TRACY LYNN WILSON MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 CENTER COURT DR STE 105
COVINA CA
91724-3672
US

IV. Provider business mailing address

16502 CASA GRANDE AVE UNIT 619
FONTANA CA
92336-6114
US

V. Phone/Fax

Practice location:
  • Phone: 626-859-2089
  • Fax: 626-859-6537
Mailing address:
  • Phone: 626-859-2089
  • Fax: 626-859-6537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: