Provider Demographics
NPI:1790170553
Name:WILSON, TERRI LYN
Entity Type:Individual
Prefix:
First Name:TERRI LYN
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:G4342 BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48506-1344
Mailing Address - Country:US
Mailing Address - Phone:810-407-3874
Mailing Address - Fax:
Practice Address - Street 1:G4342 BRANCH RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48506-1344
Practice Address - Country:US
Practice Address - Phone:810-407-3874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other