Provider Demographics
NPI:1871461277
Name:WILSON, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
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 1:770 ROCKWELL LN
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-6218
Mailing Address - Country:US
Mailing Address - Phone:347-707-3959
Mailing Address - Fax:877-599-1211
Practice Address - Street 1:1725 W 12TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-1145
Practice Address - Country:US
Practice Address - Phone:646-844-0409
Practice Address - Fax:646-838-4447
Is Sole Proprietor?:No
Enumeration Date:2025-10-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY614251174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist