Provider Demographics
NPI:1306610381
Name:WILLSON, WENDELYNN KAY (LMT)
Entity type:Individual
Prefix:
First Name:WENDELYNN
Middle Name:KAY
Last Name:WILLSON
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:N4351 MEADE ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-9541
Mailing Address - Country:US
Mailing Address - Phone:920-450-0044
Mailing Address - Fax:
Practice Address - Street 1:W6905 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:WI
Practice Address - Zip Code:54942-9099
Practice Address - Country:US
Practice Address - Phone:920-757-9887
Practice Address - Fax:920-221-3337
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5061-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist