Provider Demographics
NPI:1548415466
Name:WILSON, JULIE ANNE
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANNE
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 1:1263 CREEK SIDE CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-8229
Mailing Address - Country:US
Mailing Address - Phone:321-960-3977
Mailing Address - Fax:
Practice Address - Street 1:1982 ROCKLEDGE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3760
Practice Address - Country:US
Practice Address - Phone:321-631-5366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA#52991225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA#52991OtherDEPARTMENT OF HEALTH - MASSAGE THERAPY LICENSURE