Provider Demographics
NPI:1568914596
Name:WILSON, DEVYN JO (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:DEVYN
Middle Name:JO
Last Name:WILSON
Suffix:
Gender:F
Credentials:LAT, ATC
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 276
Mailing Address - Street 2:
Mailing Address - City:MC COMB
Mailing Address - State:OH
Mailing Address - Zip Code:45858-0276
Mailing Address - Country:US
Mailing Address - Phone:567-208-9807
Mailing Address - Fax:
Practice Address - Street 1:144 YAGER STADIUM
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056
Practice Address - Country:US
Practice Address - Phone:567-208-9807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program