Provider Demographics
NPI:1275727794
Name:WILSON, REBECCA MONIQUE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MONIQUE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:MONIQUE
Other - Last Name:HUDSPETH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4253 N CROSSOVER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4593
Mailing Address - Country:US
Mailing Address - Phone:479-521-5731
Mailing Address - Fax:479-521-6520
Practice Address - Street 1:400 E HIGHWAY 43
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-6514
Practice Address - Country:US
Practice Address - Phone:870-391-3871
Practice Address - Fax:870-741-2722
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator