Provider Demographics
NPI:1073841664
Name:WILSON, TRACI L (LAC)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 E LOUCKS ST
Mailing Address - Street 2:SUITE 014
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6339
Mailing Address - Country:US
Mailing Address - Phone:307-655-8055
Mailing Address - Fax:
Practice Address - Street 1:45 E LOUCKS ST
Practice Address - Street 2:SUITE 014
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6339
Practice Address - Country:US
Practice Address - Phone:307-655-8055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT234171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist