Provider Demographics
NPI:1730900424
Name:WILSON, EMILY INEZ (PT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:INEZ
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DRIVE
Mailing Address - Street 2:#117
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11109 PARKVIEW PLAZA DRIVE
Practice Address - Street 2:100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-266-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05015642A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist