Provider Demographics
NPI:1417693078
Name:WILSON, STEPHANIE (DC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 WOODMAN AVE APT 109
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-3073
Mailing Address - Country:US
Mailing Address - Phone:818-384-4966
Mailing Address - Fax:
Practice Address - Street 1:4441 WOODMAN AVE APT 109
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-3073
Practice Address - Country:US
Practice Address - Phone:818-384-4966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC36347111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor