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General NPI Number Information
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NPI Number | 1710383799
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Entity Type | Individual
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Provider Name | ADRIENNE ELIZABETH WILSON LMT
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Gender | Female
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Dates
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Enumeration Date | 11/18/2014
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Last Update Date | 10/21/2022
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Provider Practice Location Address
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Address Line | 16150 N HIGH DESERT ST STE 112
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City | NAMPA
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State | ID
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Zip | 83687-5567
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Country | US
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Telephone | 208-442-1123
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Fax |
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Provider Business Mailing Address
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Address Line | 700 E FAIRVIEW AVE TRLR 195
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City | MERIDIAN
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State | ID
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Zip | 83642-3325
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Country | US
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Telephone | 208-809-4987
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MASG-1863
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License Number State | ID
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