Provider Demographics
NPI:1669431235
Name:WILSON, VANESSA DARLEEN (ATC)
Entity type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:DARLEEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 S FULTON ST
Mailing Address - Street 2:APT 210
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135
Mailing Address - Country:US
Mailing Address - Phone:918-270-4039
Mailing Address - Fax:
Practice Address - Street 1:138 GRIFFIN ST NW
Practice Address - Street 2:APT 8
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30314-4073
Practice Address - Country:US
Practice Address - Phone:772-985-9636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer