Provider Demographics
NPI:1275820789
Name:WILSON, COURTNEY NICHOLE
Entity Type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:NICHOLE
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 1:3105 POINT SAL CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-8102
Mailing Address - Country:US
Mailing Address - Phone:702-525-2337
Mailing Address - Fax:
Practice Address - Street 1:3105 POINT SAL CIR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-8102
Practice Address - Country:US
Practice Address - Phone:702-525-2337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner