Provider Demographics
NPI:1710383799
Name:WILSON, ADRIENNE ELIZABETH (LMT)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:ELIZABETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E FAIRVIEW AVE TRLR 195
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3325
Mailing Address - Country:US
Mailing Address - Phone:208-809-4987
Mailing Address - Fax:
Practice Address - Street 1:16150 N HIGH DESERT ST STE 112
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-5567
Practice Address - Country:US
Practice Address - Phone:208-442-1123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-18
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-1863225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist