Healthcare Provider Details

I. General information

NPI: 1730359274
Provider Name (Legal Business Name): ANN WILSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31200 23RD AVE S
FEDERAL WAY WA
98003-5528
US

IV. Provider business mailing address

PO BOX 65330
UNIVERSITY PLACE WA
98464-1330
US

V. Phone/Fax

Practice location:
  • Phone: 253-839-3403
  • Fax: 253-839-3412
Mailing address:
  • Phone: 253-589-0611
  • Fax: 253-588-2277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4015
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: