Provider Demographics
NPI:1073757530
Name:WILSON, TRACIE E
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:E
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 1:3198 W COUNTY ROAD 500 N
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47240-9757
Mailing Address - Country:US
Mailing Address - Phone:812-593-5485
Mailing Address - Fax:812-663-8632
Practice Address - Street 1:3198 W COUNTY ROAD 500 N
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:IN
Practice Address - Zip Code:47240-9757
Practice Address - Country:US
Practice Address - Phone:812-593-5485
Practice Address - Fax:812-663-8632
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8918-41-7119172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver