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General NPI Number Information
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NPI Number | 1710878483
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Entity Type | Individual
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Provider Name | THERESA WILSON
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Gender | Female
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Dates
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Enumeration Date | 07/11/2025
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Last Update Date | 07/11/2025
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Provider Practice Location Address
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Address Line | 80 HUMPHREYS CENTER DR
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City | MEMPHIS
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State | TN
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Zip | 38120-2353
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Country | US
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Telephone | 901-226-4280
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Fax |
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Provider Business Mailing Address
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Address Line | 7123 MUNFORD GILTEDGE RD
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City | BURLISON
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State | TN
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Zip | 38015-7305
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Country | US
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Telephone | 662-216-9856
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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 | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | 204945
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License Number State | TN
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