Provider Demographics
NPI:1003063462
Name:WILSON, LINDA A (RN, MT, MMP)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, MT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12580 SAINT JAMES RD
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:76384-5726
Mailing Address - Country:US
Mailing Address - Phone:940-357-0217
Mailing Address - Fax:
Practice Address - Street 1:12580 SAINT JAMES RD
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:TX
Practice Address - Zip Code:76384-5726
Practice Address - Country:US
Practice Address - Phone:940-357-0217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX025215225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist