Healthcare Provider Details

I. General information

NPI: 1558118307
Provider Name (Legal Business Name): MS. MARI WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 05/01/2024
Certification Date: 04/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8710 116TH ST SW
LAKEWOOD WA
98498-3651
US

IV. Provider business mailing address

8710 116TH ST SW
LAKEWOOD WA
98498-3651
US

V. Phone/Fax

Practice location:
  • Phone: 253-948-2079
  • Fax:
Mailing address:
  • Phone: 253-948-2079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number603363406
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: