Provider Demographics
NPI:1841252673
Name:WILSON, ANNE JEANNETTE
Entity type:Individual
Prefix:MISS
First Name:ANNE
Middle Name:JEANNETTE
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 1:3832 E MAIN ST
Mailing Address - Street 2:UNIT E & F
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402
Mailing Address - Country:US
Mailing Address - Phone:505-564-2955
Mailing Address - Fax:505-564-2662
Practice Address - Street 1:3832 E MAIN ST
Practice Address - Street 2:UNIT E & F
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402
Practice Address - Country:US
Practice Address - Phone:505-564-2955
Practice Address - Fax:505-564-2662
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA0457225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
326561Medicare ID - Type Unspecified