Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 6149567-4701 | UT |
NPI | 1003049586 |
---|---|
Provider Name | Anneliese Wilson |
First Address | Provo, UT 84601-1518 |
Second Address | Provo, UT 84601-2821 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2009 |
Last Update Date | 22/11/2020 |