Healthcare Provider Details

I. General information

NPI: 1871042085
Provider Name (Legal Business Name): MISS REBECCA LYNN WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 WINDEMERE DR
GREENCASTLE IN
46135-9225
US

IV. Provider business mailing address

2004 WINDEMERE DR
GREENCASTLE IN
46135-9225
US

V. Phone/Fax

Practice location:
  • Phone: 765-655-3739
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: