Provider Demographics
NPI:1376356857
Name:WILSON, MEGAN
Entity type:Individual
Prefix:
First Name:MEGAN
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 1:23158 GRANITE AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63452-2449
Mailing Address - Country:US
Mailing Address - Phone:660-341-8918
Mailing Address - Fax:
Practice Address - Street 1:625 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3907
Practice Address - Country:US
Practice Address - Phone:660-341-8918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer