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General NPI Number Information
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NPI Number | 1003049586
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Entity Type | Individual
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Provider Name | ANNELIESE WILSON
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Gender | Female
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Dates
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Enumeration Date | 08/31/2009
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Last Update Date | 11/22/2020
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Provider Practice Location Address
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Address Line | 238 N UNIVERSITY AVE APT 16
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City | PROVO
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State | UT
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Zip | 84601-2821
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Country | US
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Telephone | 801-373-3484
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Fax |
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Provider Business Mailing Address
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Address Line | 710 W 800 N
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City | PROVO
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State | UT
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Zip | 84601-1518
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Country | US
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Telephone | 808-206-2158
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 10378
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License Number State | HI
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 6149567-4701
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License Number State | UT
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