Provider Demographics
NPI:1568204030
Name:WILSON, KELLY LYNN (LMT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:WILSON
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 1:4752 BUNKER RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-9781
Mailing Address - Country:US
Mailing Address - Phone:517-285-2415
Mailing Address - Fax:
Practice Address - Street 1:4752 BUNKER RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854-9781
Practice Address - Country:US
Practice Address - Phone:517-285-2415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501015844225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist