Provider Demographics
NPI:1023314853
Name:WILSON, WENDY
Entity type:Individual
Prefix:
First Name:WENDY
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 1:5625 N RED OAK DR
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-8757
Mailing Address - Country:US
Mailing Address - Phone:765-524-2407
Mailing Address - Fax:
Practice Address - Street 1:1601 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-5436
Practice Address - Country:US
Practice Address - Phone:575-623-6008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06001423A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant