Provider Demographics
NPI:1891025482
Name:WILSON, ANNETTA (PT)
Entity Type:Individual
Prefix:
First Name:ANNETTA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 N EISENHOWER ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-9588
Mailing Address - Country:US
Mailing Address - Phone:208-882-6560
Mailing Address - Fax:208-882-6569
Practice Address - Street 1:640 N EISENHOWER ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-9588
Practice Address - Country:US
Practice Address - Phone:208-882-6560
Practice Address - Fax:208-882-6569
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT-80174400000X
IDPT-00000493174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist