Provider Demographics
NPI:1376964684
Name:WILSON, ALICIA
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
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 1:8352 ROSWELL RD APT ROSWELL
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-2812
Mailing Address - Country:US
Mailing Address - Phone:770-837-5777
Mailing Address - Fax:
Practice Address - Street 1:8740 ROSWELL RD UNIT 10D
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30350-1831
Practice Address - Country:US
Practice Address - Phone:770-837-5577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-05
Last Update Date:2021-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA885121133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered