Provider Demographics
NPI:1770246118
Name:WILSON, MONIKA V
Entity Type:Individual
Prefix:
First Name:MONIKA
Middle Name:V
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 1:110 CROSS PARK DR
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-9016
Mailing Address - Country:US
Mailing Address - Phone:601-506-5784
Mailing Address - Fax:
Practice Address - Street 1:110 CROSS PARK DR
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-9016
Practice Address - Country:US
Practice Address - Phone:601-506-5784
Practice Address - Fax:601-397-6732
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty