Provider Demographics
NPI:1003049586
Name:WILSON, ANNELIESE
Entity Type:Individual
Prefix:
First Name:ANNELIESE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 W 800 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1518
Mailing Address - Country:US
Mailing Address - Phone:808-206-2158
Mailing Address - Fax:
Practice Address - Street 1:238 N UNIVERSITY AVE APT 16
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-2821
Practice Address - Country:US
Practice Address - Phone:801-373-3484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-31
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI10378174400000X
UT6149567-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist