Healthcare Provider Details

I. General information

NPI: 1942211610
Provider Name (Legal Business Name): LAURA WILSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

368 NIKOMAS WAY
MELBOURNE BEACH FL
32951-3527
US

IV. Provider business mailing address

368 NIKOMAS WAY
MELBOURNE BEACH FL
32951-3527
US

V. Phone/Fax

Practice location:
  • Phone: 321-676-4684
  • Fax: 321-725-9907
Mailing address:
  • Phone: 321-676-4684
  • Fax: 321-725-9907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 16884
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: