Provider Demographics
NPI:1609076736
Name:WILSON, REBECCA KAREN
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:KAREN
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 1:6464 BRENTWOOD STAIR RD STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-3242
Mailing Address - Country:US
Mailing Address - Phone:817-496-0095
Mailing Address - Fax:
Practice Address - Street 1:6464 BRENTWOOD STAIR RD STE 201
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-3242
Practice Address - Country:US
Practice Address - Phone:817-496-0095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy