Healthcare Provider Details

I. General information

NPI: 1912032624
Provider Name (Legal Business Name): EDIE M WILSON LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N PINES RD
SPOKANE VALLEY WA
99206-4964
US

IV. Provider business mailing address

PO BOX 81
SMELTERVILLE ID
83868-0081
US

V. Phone/Fax

Practice location:
  • Phone: 509-922-5585
  • Fax: 509-927-7336
Mailing address:
  • Phone: 208-755-5998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00016218
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: