Provider Demographics
NPI:1760958599
Name:WILSON, MARIAH DAWN (ND)
Entity Type:Individual
Prefix:DR
First Name:MARIAH
Middle Name:DAWN
Last Name:WILSON
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3180 RACQUET CLUB DR STE B
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4797
Mailing Address - Country:US
Mailing Address - Phone:231-252-9000
Mailing Address - Fax:
Practice Address - Street 1:3180 RACQUET CLUB DR STE B
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4797
Practice Address - Country:US
Practice Address - Phone:231-252-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT099.0134060175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath