Provider Demographics
NPI:1821833328
Name:WILSON, BRANDY MIKEL (PTA)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:MIKEL
Last Name:WILSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:BRANDY
Other - Middle Name:MIKEL
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:3000 ORLEANS ST # 102
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-3542
Mailing Address - Country:US
Mailing Address - Phone:907-713-4259
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 634
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-0634
Practice Address - Country:US
Practice Address - Phone:360-966-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2025-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP161515318225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant