Provider Demographics
NPI:1902178148
Name:WILSON, ASHLEY BONCK (MHR, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:BONCK
Last Name:WILSON
Suffix:
Gender:F
Credentials:MHR, ATC, LAT
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:KAY
Other - Last Name:BONCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MHR, ATC, LAT
Mailing Address - Street 1:36 HILL DRIVE
Mailing Address - Street 2:BASKETBALL PRACTICE FACILITY
Mailing Address - City:UNIVERSITY
Mailing Address - State:MS
Mailing Address - Zip Code:38677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 HILL DRIVE
Practice Address - Street 2:BASKETBALL PRACTICE FACILITY
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38677
Practice Address - Country:US
Practice Address - Phone:662-915-1375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT05512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer