Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 227006030 | IL |
NPI | 1497155824 |
---|---|
Provider Name | Krystal Wilson |
First Address | Mokena, IL 60448-9321 |
Second Address | Mokena, IL 60448-9321 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/09/2014 |
Last Update Date | 04/09/2014 |