Provider Demographics
NPI:1447774484
Name:WILSON, ALEXANDRA ERIN (BS, ATC)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:ERIN
Last Name:WILSON
Suffix:
Gender:F
Credentials:BS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COLLEGE PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8660
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 COLLEGE PARK DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8660
Practice Address - Country:US
Practice Address - Phone:314-434-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170260922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer