MEDICARE: LAKEISHA ALAINA WILSON

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	372600000X	Adult Companion	OH
2	3747P1801X	Personal Care Attendant	OH
3	172A00000X	Driver	OH

General Provider Information

NPI Number	:	1902670714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKEISHA ALAINA WILSON

Provider Business Mailing Address
First Line	:	4609 KAMMER AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45417-1135
Country	:	US
Telephone Number	:	937-793-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	4609 KAMMER AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45417-1135
Country	:	US
Telephone Number	:	937-793-9200
Fax Number	:

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

Provider Enumeration Date	:	11/13/2023
Last Update Date	:	11/13/2023

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