Healthcare Provider Details

I. General information

NPI: 1669431235
Provider Name (Legal Business Name): VANESSA DARLEEN WILSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 GRIFFIN ST NW APT 8
ATLANTA GA
30314-4073
US

IV. Provider business mailing address

4747 S FULTON ST APT 210
TULSA OK
74135
US

V. Phone/Fax

Practice location:
  • Phone: 772-985-9636
  • Fax:
Mailing address:
  • Phone: 918-270-4039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: