Provider Demographics
NPI:1285709642
Name:WILSON, MARY LYNN (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 893
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20118-0893
Mailing Address - Country:US
Mailing Address - Phone:540-687-6565
Mailing Address - Fax:540-687-6585
Practice Address - Street 1:204 E FEDERAL ST.
Practice Address - Street 2:SUITE C
Practice Address - City:MIDDLEBURG
Practice Address - State:VA
Practice Address - Zip Code:20117
Practice Address - Country:US
Practice Address - Phone:540-687-6565
Practice Address - Fax:540-687-6585
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004796225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00V695D88Medicare ID - Type Unspecified