Provider Demographics
NPI:1437280096
Name:WILSON, TIFFANY LYNN (OTRL)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 SUNNINGDALE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-8514
Mailing Address - Country:US
Mailing Address - Phone:859-264-0242
Mailing Address - Fax:
Practice Address - Street 1:1740 NICHOLASVILLE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1431
Practice Address - Country:US
Practice Address - Phone:859-260-6144
Practice Address - Fax:859-260-6430
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R1330225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist