Provider Demographics
NPI:1861001240
Name:WILSON, TAMARAH JANEICE
Entity Type:Individual
Prefix:
First Name:TAMARAH
Middle Name:JANEICE
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 1:19752 SEHORN ST
Mailing Address - Street 2:
Mailing Address - City:SPIRO
Mailing Address - State:OK
Mailing Address - Zip Code:74959-4418
Mailing Address - Country:US
Mailing Address - Phone:918-208-1669
Mailing Address - Fax:
Practice Address - Street 1:619 PARKVIEW ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-2703
Practice Address - Country:US
Practice Address - Phone:479-474-8730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1215224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant