Provider Demographics
NPI:1518484971
Name:WILSON, ALEXANDRIA NOELLE (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:NOELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4475 W PINE BLVD APT 604
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2315
Mailing Address - Country:US
Mailing Address - Phone:661-809-7604
Mailing Address - Fax:
Practice Address - Street 1:3518 LACLEDE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2011
Practice Address - Country:US
Practice Address - Phone:314-977-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-26
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1363641225100000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer