Provider Demographics
NPI:1093914285
Name:WILSON, ILA NELL (MS, CCC-A)
Entity Type:Individual
Prefix:
First Name:ILA
Middle Name:NELL
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 NW 56TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4463
Mailing Address - Country:US
Mailing Address - Phone:405-949-1906
Mailing Address - Fax:405-945-7189
Practice Address - Street 1:3400 NW 56TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4463
Practice Address - Country:US
Practice Address - Phone:405-949-1906
Practice Address - Fax:405-945-7189
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK113231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist