MEDICARE: CHRISTINA NICOLE WILSON

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	235Z00000X	Speech-Language Pathologist	2202005288	VA

General Provider Information

NPI Number	:	1851599492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA NICOLE WILSON

Provider Business Mailing Address
First Line	:	5631 5TH ST N
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22205-1005
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5631 5TH ST N
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22205-1005
Country	:	US
Telephone Number	:	918-852-5291
Fax Number	:

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

Provider Enumeration Date	:	07/05/2007
Last Update Date	:	05/20/2008

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Directions to “ CHRISTINA NICOLE WILSON ” Practice Location

Language	Start Address	Practice Location

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