Provider Demographics
NPI:1487532255
Name:WILSON, SOPHIA
Entity type:Individual
Prefix:
First Name:SOPHIA
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 1:6301 BEACH BLVD STE 245
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-4031
Mailing Address - Country:US
Mailing Address - Phone:714-736-0231
Mailing Address - Fax:714-736-0231
Practice Address - Street 1:6301 BEACH BLVD STE 25
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2840
Practice Address - Country:US
Practice Address - Phone:714-736-0231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program