Provider Demographics
NPI:1861100257
Name:WILSON, NOELLE JOSEPHINE (BKIN, MSCPT, DPT)
Entity type:Individual
Prefix:
First Name:NOELLE
Middle Name:JOSEPHINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:BKIN, MSCPT, DPT
Other - Prefix:
Other - First Name:NOELLE
Other - Middle Name:JOSEPHINE
Other - Last Name:MACDOUGALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BKIN, MSCPT, DPT
Mailing Address - Street 1:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-0393
Mailing Address - Country:US
Mailing Address - Phone:780-938-5944
Mailing Address - Fax:
Practice Address - Street 1:28210 OLD TOWNE RD
Practice Address - Street 2:
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-9556
Practice Address - Country:US
Practice Address - Phone:651-257-0575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4991208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation