Healthcare Provider Details

I. General information

NPI: 1316421795
Provider Name (Legal Business Name): CHLOE LYN WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4342 15TH AVE S STE 105
FARGO ND
58103-1125
US

IV. Provider business mailing address

1528 35TH AVE S
MOORHEAD MN
56560-6972
US

V. Phone/Fax

Practice location:
  • Phone: 701-936-9495
  • Fax:
Mailing address:
  • Phone: 701-540-7605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number00000
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: