Provider Demographics
NPI:1346742343
Name:WILSON, KRISTIN MANNINA (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MANNINA
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2029 LONGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2814
Mailing Address - Country:US
Mailing Address - Phone:919-280-1436
Mailing Address - Fax:
Practice Address - Street 1:5301 CREEDMOOR RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-3822
Practice Address - Country:US
Practice Address - Phone:919-651-3803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11976225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist