Healthcare Provider Details

I. General information

NPI: 1891025482
Provider Name (Legal Business Name): ANNETTA WILSON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 01/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 N EISENHOWER ST
MOSCOW ID
83843-9588
US

IV. Provider business mailing address

640 N EISENHOWER ST
MOSCOW ID
83843-9588
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-6560
  • Fax: 208-882-6569
Mailing address:
  • Phone: 208-882-6560
  • Fax: 208-882-6569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT-80
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT-00000493
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: