=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679820971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANN W WILSON PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2012
-----------------------------------------------------
Last Update Date | 08/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4750 WESLEY AVE
-----------------------------------------------------
City | NORWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45212-2244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-458-8837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9771 TALL TIMBER DR
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45241-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-777-3433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 003323
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------