MEDICARE: MS. VANESSA DARLEEN WILSON ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1669431235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VANESSA DARLEEN WILSON ATC

Provider Business Mailing Address
First Line	:	4747 S FULTON ST
Second Line	:	APT 210
City	:	TULSA
State	:	OK
Zip	:	74135
Country	:	US
Telephone Number	:	918-270-4039
Fax Number	:

Provider Business Practice Location Address
First Line	:	138 GRIFFIN ST NW
Second Line	:	APT 8
City	:	ATLANTA
State	:	GA
Zip	:	30314-4073
Country	:	US
Telephone Number	:	772-985-9636
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	02/18/2009

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