Provider Demographics
NPI:1437039237
Name:WILSON, MICHELLE (CST, CSFA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CST, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 KANSAS DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-1424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:IN
Practice Address - Zip Code:46542-3006
Practice Address - Country:US
Practice Address - Phone:574-832-6246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN129513246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant