Provider Demographics
NPI:1558992057
Name:WILSON, STEPHANIE R
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:GOODWIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5308 WAPAKONATA TRL SW
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30054-3335
Mailing Address - Country:US
Mailing Address - Phone:901-239-8461
Mailing Address - Fax:
Practice Address - Street 1:5308 WAPAKONATA TRL SW
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:GA
Practice Address - Zip Code:30054-3335
Practice Address - Country:US
Practice Address - Phone:901-239-8461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantDriving and Community Mobility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA844551151OtherTRANSPORTATION