Individual
BERNICE WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
4202 BUELL DR, FORT WAYNE, IN 46807-2743
(260) 341-4756
Mailing address
4202 BUELL DR, FORT WAYNE, IN 46807-2743
(260) 341-4756
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
32001561A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
32001561A
COTA
IN
Enumeration date
01/31/2008
Last updated
01/31/2008
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