MEDICARE: MRS. BERNADETTE CELESTE WILSON LPN

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	164W00000X	Licensed Practical Nurse	PN112254	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154523637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BERNADETTE CELESTE WILSON LPN

Provider Business Mailing Address
First Line	:	5732 ROSEBURY DR
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-4352
Country	:	US
Telephone Number	:	937-236-1931
Fax Number	:	937-236-1931

Provider Business Practice Location Address
First Line	:	5732 ROSEBURY DR
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-4352
Country	:	US
Telephone Number	:	937-236-1931
Fax Number	:	937-236-1931

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

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	07/09/2007

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