Provider Demographics
NPI:1932524279
Name:WILSON, STORMY
Entity type:Individual
Prefix:
First Name:STORMY
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 1:800 S FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50213-1619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15500 555TH ST
Practice Address - Street 2:
Practice Address - City:LUCAS
Practice Address - State:IA
Practice Address - Zip Code:50151-8473
Practice Address - Country:US
Practice Address - Phone:641-342-5340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist