Provider Demographics
NPI:1760212831
Name:WILSON, NINA (MSAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1172 E BROADWAY UNIT 315
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1885
Mailing Address - Country:US
Mailing Address - Phone:985-237-2860
Mailing Address - Fax:
Practice Address - Street 1:2126 S FLOYD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-2751
Practice Address - Country:US
Practice Address - Phone:985-237-2860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA38942255A2300X
KYTCA0402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer