Provider Demographics
NPI:1235825969
Name:WILSON, CHANDA
Entity Type:Individual
Prefix:MS
First Name:CHANDA
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 1:2091 SILVER BELL RD APT 46
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1045
Mailing Address - Country:US
Mailing Address - Phone:612-223-3449
Mailing Address - Fax:
Practice Address - Street 1:2091 SILVER BELL RD APT 46
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-1045
Practice Address - Country:US
Practice Address - Phone:612-223-3449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2023075225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist