Provider Demographics
NPI:1821295049
Name:WILSON, DIANE ALICE (RPT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ALICE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 N PINEVIEW ST
Mailing Address - Street 2:
Mailing Address - City:STANBERRY
Mailing Address - State:MO
Mailing Address - Zip Code:64489-1509
Mailing Address - Country:US
Mailing Address - Phone:660-783-2118
Mailing Address - Fax:
Practice Address - Street 1:307 N PINEVIEW ST
Practice Address - Street 2:
Practice Address - City:STANBERRY
Practice Address - State:MO
Practice Address - Zip Code:64489-1509
Practice Address - Country:US
Practice Address - Phone:660-783-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO00988172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist