Provider Demographics
NPI:1801349162
Name:WILSON, KELLY DIANE (MS, ATC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DIANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 CENTER ST
Mailing Address - Street 2:APT C-1
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-2781
Mailing Address - Country:US
Mailing Address - Phone:562-293-5600
Mailing Address - Fax:
Practice Address - Street 1:55 FAIR DR
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-6520
Practice Address - Country:US
Practice Address - Phone:714-619-6618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program