Healthcare Provider Details

I. General information

NPI: 1306610381
Provider Name (Legal Business Name): WENDELYNN KAY WILLSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2023
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W6905 PARKVIEW DR
GREENVILLE WI
54942-9099
US

IV. Provider business mailing address

N4351 MEADE ST
APPLETON WI
54913-9541
US

V. Phone/Fax

Practice location:
  • Phone: 920-757-9887
  • Fax: 920-221-3337
Mailing address:
  • Phone: 920-450-0044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5061-146
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: