Healthcare Provider Details

I. General information

NPI: 1043479330
Provider Name (Legal Business Name): E JOAN WILSON CLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 STONE LAKE ROAD
DULCE NM
87528
US

IV. Provider business mailing address

PO BOX 1403
OCEAN PARK WA
98640
US

V. Phone/Fax

Practice location:
  • Phone: 505-759-7238
  • Fax:
Mailing address:
  • Phone: 360-665-4599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZI1000X
TaxonomyMedical Illustrator
License Number9905528
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: