MEDICARE: VANEIQUA WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1053192484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANEIQUA WILSON

Provider Business Mailing Address
First Line	:	3530 FRANCIS LEWIS BLVD STE 204
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11358-1959
Country	:	US
Telephone Number	:	718-939-0306
Fax Number	:

Provider Business Practice Location Address
First Line	:	3530 FRANCIS LEWIS BLVD STE 204
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11358-1959
Country	:	US
Telephone Number	:	718-939-0306
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2023
Last Update Date	:	10/11/2023

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Directions to “ VANEIQUA WILSON ” Practice Location

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