Provider Demographics
NPI:1619100617
Name:WILSON, ANITA
Entity Type:Individual
Prefix:MS
First Name:ANITA
Middle Name:
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:PO BOX 1452
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-1452
Mailing Address - Country:US
Mailing Address - Phone:307-332-7825
Mailing Address - Fax:307-332-7596
Practice Address - Street 1:309 DEL ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3439
Practice Address - Country:US
Practice Address - Phone:307-332-7825
Practice Address - Fax:307-332-7596
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator