Provider Demographics
NPI:1649582784
Name:WILKERSON, AUDREY J (PTA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:J
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 LAFAYETTE 243
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:AR
Mailing Address - Zip Code:71861-8825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 E STADIUM
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2032
Practice Address - Country:US
Practice Address - Phone:870-234-7604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA2194225200000X
LAPTA6575225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant