Healthcare Provider Details

I. General information

NPI: 1669679239
Provider Name (Legal Business Name): DARA RENA WILSON D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 WALTERS LN SUITE 14
FORESTVILLE MD
20747-3247
US

IV. Provider business mailing address

1109 SUMMIT AVE
GREENSBORO NC
27405-6747
US

V. Phone/Fax

Practice location:
  • Phone: 301-420-8888
  • Fax: 301-420-8838
Mailing address:
  • Phone: 410-578-3993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberS02081
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: