Provider Demographics
NPI:1053774786
Name:WILSON, MERRILY YVONNE (LMT)
Entity type:Individual
Prefix:MRS
First Name:MERRILY
Middle Name:YVONNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MRS
Other - First Name:MERRILY
Other - Middle Name:YVONNE
Other - Last Name:ORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:409 EARHART ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-7827
Mailing Address - Country:US
Mailing Address - Phone:541-858-8887
Mailing Address - Fax:
Practice Address - Street 1:409 EARHART ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-7827
Practice Address - Country:US
Practice Address - Phone:541-858-8887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5083225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist