Healthcare Provider Details

I. General information

NPI: 1962313437
Provider Name (Legal Business Name): REBECCA ANN WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6618 32ND ST S
FARGO ND
58104-3529
US

IV. Provider business mailing address

6618 32ND ST S
FARGO ND
58104-3529
US

V. Phone/Fax

Practice location:
  • Phone: 701-730-1820
  • Fax:
Mailing address:
  • Phone: 701-730-1820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberFEL-73-7343
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: