Provider Demographics
NPI:1154549814
Name:WILSON, HOLLY M (LMT)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5153 CO. RD. 16
Mailing Address - Street 2:
Mailing Address - City:PEDRO
Mailing Address - State:OH
Mailing Address - Zip Code:45659
Mailing Address - Country:US
Mailing Address - Phone:740-643-2396
Mailing Address - Fax:
Practice Address - Street 1:221 S. 6TH ST.
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638
Practice Address - Country:US
Practice Address - Phone:740-533-0550
Practice Address - Fax:740-534-1111
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH16010174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist