Provider Demographics
NPI:1649791443
Name:WILSON, ELIZA JEAN
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:JEAN
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 1:7235 N 185TH AVE
Mailing Address - Street 2:
Mailing Address - City:WADDELL
Mailing Address - State:AZ
Mailing Address - Zip Code:85355-9812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7235 N 185TH AVE
Practice Address - Street 2:
Practice Address - City:WADDELL
Practice Address - State:AZ
Practice Address - Zip Code:85355-9812
Practice Address - Country:US
Practice Address - Phone:623-695-1973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer