Provider Demographics
NPI:1992936082
Name:WILSON, KELE ELIZABETH
Entity type:Individual
Prefix:
First Name:KELE
Middle Name:ELIZABETH
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:P.O. BOX 333
Mailing Address - Street 2:
Mailing Address - City:WARD
Mailing Address - State:AR
Mailing Address - Zip Code:72176
Mailing Address - Country:US
Mailing Address - Phone:501-941-5630
Mailing Address - Fax:501-843-2270
Practice Address - Street 1:1500 WILSON LOOP ROAD
Practice Address - Street 2:
Practice Address - City:WARD
Practice Address - State:AR
Practice Address - Zip Code:72176
Practice Address - Country:US
Practice Address - Phone:501-941-5630
Practice Address - Fax:501-843-2270
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR772225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129951721Medicaid