Provider Demographics
NPI:1568423614
Name:WILSON, ANGIE (DC)
Entity Type:Individual
Prefix:DR
First Name:ANGIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:42539-0340
Mailing Address - Country:US
Mailing Address - Phone:606-787-2800
Mailing Address - Fax:606-787-2880
Practice Address - Street 1:69 HUSTONVILLE ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:42539-3160
Practice Address - Country:US
Practice Address - Phone:606-787-2800
Practice Address - Fax:606-787-2880
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4896111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6101502Medicare ID - Type Unspecified
KYV01113Medicare UPIN