Provider Demographics
NPI:1437922499
Name:WILSON, JOY ANN ELAINE (RDA)
Entity Type:Individual
Prefix:
First Name:JOY ANN
Middle Name:ELAINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:MRS
Other - First Name:JOY ANN
Other - Middle Name:ELAINE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:JOY ANN E MARTIN
Mailing Address - Street 1:5066 BROOKLAWN PL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-1811
Mailing Address - Country:US
Mailing Address - Phone:951-966-7374
Mailing Address - Fax:
Practice Address - Street 1:5066 BROOKLAWN PL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-1811
Practice Address - Country:US
Practice Address - Phone:951-966-7374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA28952126800000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No126800000XDental ProvidersDental Assistant