Provider Demographics
NPI:1629135363
Name:WILSON, NATASHA MARILYN (DC)
Entity Type:Individual
Prefix:DR
First Name:NATASHA
Middle Name:MARILYN
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 1:1296 BROUGHTON ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-5963
Mailing Address - Country:US
Mailing Address - Phone:803-534-2133
Mailing Address - Fax:
Practice Address - Street 1:1296 BROUGHTON ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-5963
Practice Address - Country:US
Practice Address - Phone:803-534-2133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCCH2913111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor