Provider Demographics
NPI:1376029512
Name:WILSON, NATALIE ELISE (CPO)
Entity Type:Individual
Prefix:MISS
First Name:NATALIE
Middle Name:ELISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1577 E CHEVY CHASE DR STE 210
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4741
Mailing Address - Country:US
Mailing Address - Phone:818-495-4610
Mailing Address - Fax:818-484-2812
Practice Address - Street 1:1577 E CHEVY CHASE DR STE 210
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4741
Practice Address - Country:US
Practice Address - Phone:818-495-4610
Practice Address - Fax:818-484-2812
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO04121222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist