Healthcare Provider Details

I. General information

NPI: 1437722949
Provider Name (Legal Business Name): WANDA TERRELL MOORE- WILSON MB&C, CNA,MOA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 11/19/2023
Certification Date: 11/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5612 S WABASH AVE # APTY5
CHICAGO IL
60637-1155
US

IV. Provider business mailing address

5612 S WABASH AVE APT 5
CHICAGO IL
60637-1155
US

V. Phone/Fax

Practice location:
  • Phone: 312-481-3779
  • Fax:
Mailing address:
  • Phone: 312-481-3779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: