Provider Demographics
NPI:1447674577
Name:WILSON, AZURE CELESTE (MS)
Entity type:Individual
Prefix:
First Name:AZURE
Middle Name:CELESTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:AZURE
Other - Middle Name:CELESTE
Other - Last Name:WALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6273 SILVER FOX TRL
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-1308
Mailing Address - Country:US
Mailing Address - Phone:423-353-4390
Mailing Address - Fax:
Practice Address - Street 1:6273 SILVER FOX TRL
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-1308
Practice Address - Country:US
Practice Address - Phone:423-353-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000604326235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist