Provider Demographics
NPI:1376392142
Name:WILSON, EMMA
Entity type:Individual
Prefix:
First Name:EMMA
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 1:8299 ARMETALE LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX STATION
Mailing Address - State:VA
Mailing Address - Zip Code:22039-3112
Mailing Address - Country:US
Mailing Address - Phone:703-598-5671
Mailing Address - Fax:
Practice Address - Street 1:103 WESTEDGE WAY
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-5901
Practice Address - Country:US
Practice Address - Phone:434-200-8215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305216501225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist