Provider Demographics
NPI:1114461555
Name:WILSON, CRYSTIN
Entity Type:Individual
Prefix:MISS
First Name:CRYSTIN
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 1:403 S SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-9292
Mailing Address - Country:US
Mailing Address - Phone:816-500-6273
Mailing Address - Fax:
Practice Address - Street 1:411 CENTRAL METHODIST SQ
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MO
Practice Address - Zip Code:65248-1104
Practice Address - Country:US
Practice Address - Phone:816-500-6273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-04
Last Update Date:2016-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer