Provider Demographics
NPI:1154020295
Name:WILSON, ALYSSA (PT)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1228 KIRKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HUMESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50123-8041
Mailing Address - Country:US
Mailing Address - Phone:712-520-0041
Mailing Address - Fax:
Practice Address - Street 1:1228 KIRKWOOD RD
Practice Address - Street 2:
Practice Address - City:HUMESTON
Practice Address - State:IA
Practice Address - Zip Code:50123-8041
Practice Address - Country:US
Practice Address - Phone:712-520-0041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist