Provider Demographics
NPI:1689784068
Name:WILSON, CHRISTINE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
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 1:397 JAMES FRAZIER RD
Mailing Address - Street 2:
Mailing Address - City:LACEYS SPRING
Mailing Address - State:AL
Mailing Address - Zip Code:35754-7312
Mailing Address - Country:US
Mailing Address - Phone:256-778-0436
Mailing Address - Fax:
Practice Address - Street 1:4725 WHITESBURG DR S
Practice Address - Street 2:STE 201
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-1665
Practice Address - Country:US
Practice Address - Phone:256-880-7776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPTA 3643OtherLICENSE #