MEDICARE: MS. BONNIE LEE 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	PN029260	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	:	1447462593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BONNIE LEE WILSON LPN

Provider Business Mailing Address
First Line	:	1212 HANLEY RD W
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44904
Country	:	US
Telephone Number	:	419-512-3377
Fax Number	:	419-884-7368

Provider Business Practice Location Address
First Line	:	1212 HANLEY RD W
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44904
Country	:	US
Telephone Number	:	419-512-3379
Fax Number	:	419-884-7368

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

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	03/29/2016

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