Provider Demographics
NPI:1366303216
Name:WILSON, TONI A
Entity type:Individual
Prefix:
First Name:TONI
Middle Name:A
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 1:1047 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435-2561
Mailing Address - Country:US
Mailing Address - Phone:575-815-9076
Mailing Address - Fax:
Practice Address - Street 1:1047 LAKE DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435-2561
Practice Address - Country:US
Practice Address - Phone:575-815-9076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-20
Last Update Date:2025-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty