=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538741376
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISHA L WILSON- FRIDGE LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2021
-----------------------------------------------------
Last Update Date | 04/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 E ROOSEVELT RD APT 514
-----------------------------------------------------
City | LOMBARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148-4539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-920-0205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 E ROOSEVELT RD APT 514
-----------------------------------------------------
City | LOMBARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148-4539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-920-0205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 227.009496
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------