Provider Demographics
NPI:1528624830
Name:WILSON, EMMA MAE (RD)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:MAE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 E CIMARRON HILL CT
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-8574
Mailing Address - Country:US
Mailing Address - Phone:405-623-4059
Mailing Address - Fax:
Practice Address - Street 1:4100 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45428-9000
Practice Address - Country:US
Practice Address - Phone:405-623-4059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered