Provider Demographics
NPI:1245351519
Name:WILSON, PAMELA LYNN (OTRL LMT)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTRL LMT
Other - Prefix:MRS
Other - First Name:PAMELA
Other - Middle Name:L
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTRL LMT
Mailing Address - Street 1:PO BOX 90605
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-0605
Mailing Address - Country:US
Mailing Address - Phone:505-255-1000
Mailing Address - Fax:505-255-1000
Practice Address - Street 1:8712 VINEYARD RIDGE RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-2624
Practice Address - Country:US
Practice Address - Phone:505-255-1000
Practice Address - Fax:505-255-1000
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1787225X00000X
NM517225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist