Provider Demographics
NPI:1295228211
Name:WILSON, MYCHAL ANN (LMT)
Entity Type:Individual
Prefix:
First Name:MYCHAL
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 E TUDOR RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-7371
Mailing Address - Country:US
Mailing Address - Phone:907-222-2100
Mailing Address - Fax:907-222-2131
Practice Address - Street 1:550 E TUDOR RD STE 101
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-7371
Practice Address - Country:US
Practice Address - Phone:907-222-2100
Practice Address - Fax:907-222-2131
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK131947225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist