Basic Information
| Provider Information | |||||||||
| NPI: | 1356547475 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MARNI | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | AAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24366 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981240366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065980502 | ||||||||
| FaxNumber: | 2065980516 | ||||||||
| Practice Location | |||||||||
| Address1: | 4245 ROOSEVELT WAY NE | ||||||||
| Address2: | BOX 354745 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981056008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065982888 | ||||||||
| FaxNumber: | 2065984484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 06/05/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.