Healthcare Provider Details

I. General information

NPI: 1023314853
Provider Name (Legal Business Name): WENDY WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2011
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 S MAIN ST
ROSWELL NM
88203-5436
US

IV. Provider business mailing address

5625 N RED OAK DR
GREENFIELD IN
46140-8757
US

V. Phone/Fax

Practice location:
  • Phone: 575-623-6008
  • Fax:
Mailing address:
  • Phone: 765-524-2407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06001423A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: