Provider Demographics
NPI:1710878483
Name:WILSON, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
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 1:7123 MUNFORD GILTEDGE RD
Mailing Address - Street 2:
Mailing Address - City:BURLISON
Mailing Address - State:TN
Mailing Address - Zip Code:38015-7305
Mailing Address - Country:US
Mailing Address - Phone:662-216-9856
Mailing Address - Fax:
Practice Address - Street 1:80 HUMPHREYS CENTER DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2353
Practice Address - Country:US
Practice Address - Phone:901-226-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-11
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN204945246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant