Healthcare Provider Details

I. General information

NPI: 1326786765
Provider Name (Legal Business Name): SHAMEKA DAYSHAN WILSON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5350 TOMAH DR STE 3600
COLORADO SPRINGS CO
80918-6991
US

IV. Provider business mailing address

5350 TOMAH DR STE 3600
COLORADO SPRINGS CO
80918-6991
US

V. Phone/Fax

Practice location:
  • Phone: 970-806-4972
  • Fax: 888-965-4615
Mailing address:
  • Phone: 970-806-4972
  • Fax: 888-965-4615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2020131915
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberC-APN.0102397-C-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: