Provider Demographics
NPI:1902017858
Name:WILSON, KIMBERLIE ANNE (LAC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLIE
Middle Name:ANNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 SEDGWICK AVE APT 3A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-4468
Mailing Address - Country:US
Mailing Address - Phone:718-902-6715
Mailing Address - Fax:
Practice Address - Street 1:TRS, INC.
Practice Address - Street 2:44 EAST 32ND ST. 11TH FL.
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10463
Practice Address - Country:US
Practice Address - Phone:718-902-6715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1210171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist