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General NPI Number Information
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NPI Number | 1861001240
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Entity Type | Individual
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Provider Name | TAMARAH JANEICE WILSON
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Gender | Female
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Dates
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Enumeration Date | 07/30/2020
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Last Update Date | 07/30/2020
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Provider Practice Location Address
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Address Line | 619 PARKVIEW ST
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City | VAN BUREN
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State | AR
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Zip | 72956-2703
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Country | US
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Telephone | 479-474-8730
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Fax |
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Provider Business Mailing Address
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Address Line | 19752 SEHORN ST
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City | SPIRO
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State | OK
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Zip | 74959-4418
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Country | US
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Telephone | 918-208-1669
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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 | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | OT-A1215
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License Number State | AR
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