Provider Demographics
NPI:1699892612
Name:WILSON, TRACY LYNN (MS)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 S ARCHIBALD AVE APT 183
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-7984
Mailing Address - Country:US
Mailing Address - Phone:626-859-2089
Mailing Address - Fax:626-859-6537
Practice Address - Street 1:2200 E ROUTE 66
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740
Practice Address - Country:US
Practice Address - Phone:626-859-2089
Practice Address - Fax:626-859-6537
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner