Healthcare Provider Details

I. General information

NPI: 1386134666
Provider Name (Legal Business Name): VICTORIA KALENE WILSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2018
Last Update Date: 05/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MACARTHUR BLVD STE 405
MUNSTER IN
46321-2919
US

IV. Provider business mailing address

13740 N AYRSHIRE CIR
CAMBY IN
46113-9635
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-4461
  • Fax:
Mailing address:
  • Phone: 317-292-2014
  • 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: