Provider Demographics
NPI:1396925731
Name:WILSON, MICHELLE (LAC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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 1:83377 SPRUCE LN
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-8322
Mailing Address - Country:US
Mailing Address - Phone:206-931-4500
Mailing Address - Fax:541-991-3918
Practice Address - Street 1:1845 HIGHWAY 126 UNIT H
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-9626
Practice Address - Country:US
Practice Address - Phone:541-991-3917
Practice Address - Fax:541-991-3918
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC198662171100000X
WAAC00002944171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist