Provider Demographics
NPI:1821827569
Name:WILSON, TIKKRI
Entity type:Individual
Prefix:
First Name:TIKKRI
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 1:2807 E BROOKWOOD CT
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7742
Mailing Address - Country:US
Mailing Address - Phone:602-568-7656
Mailing Address - Fax:
Practice Address - Street 1:2807 E BROOKWOOD CT
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7742
Practice Address - Country:US
Practice Address - Phone:602-568-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9388544251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health