Provider Demographics
NPI:1700140480
Name:WILSON, TERESA ANN
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:ANN
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 1:3150 S NELLIS BLVD APT 1189
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-7537
Mailing Address - Country:US
Mailing Address - Phone:559-790-8842
Mailing Address - Fax:
Practice Address - Street 1:3150 S NELLIS BLVD APT 1189
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-7537
Practice Address - Country:US
Practice Address - Phone:559-790-8842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner