Healthcare Provider Details

I. General information

NPI: 1659912657
Provider Name (Legal Business Name): SIDRA ANN WILSON LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 W VISTA WAY
VISTA CA
92083-5704
US

IV. Provider business mailing address

524 W VISTA WAY
VISTA CA
92083-5704
US

V. Phone/Fax

Practice location:
  • Phone: 760-305-4900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number181732
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: