Provider Demographics
NPI:1841152097
Name:WILSON, FATE
Entity type:Individual
Prefix:
First Name:FATE
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 WADE HAMPTON BLVD STE A-3
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-4940
Mailing Address - Country:US
Mailing Address - Phone:864-772-3273
Mailing Address - Fax:
Practice Address - Street 1:726 WADE HAMPTON BLVD STE A-3
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-4940
Practice Address - Country:US
Practice Address - Phone:864-772-3273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-25
Last Update Date:2025-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach