Provider Demographics
NPI:1487212676
Name:WILSON, MISTY
Entity Type:Individual
Prefix:
First Name:MISTY
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 1:170 STARE RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-4723
Mailing Address - Country:US
Mailing Address - Phone:740-404-9581
Mailing Address - Fax:
Practice Address - Street 1:445 E DUBLIN GRANVILLE RD
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-3192
Practice Address - Country:US
Practice Address - Phone:614-436-7837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator