Healthcare Provider Details

I. General information

NPI: 1891455168
Provider Name (Legal Business Name): TYIESHA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 W LAKE ST
CHICAGO IL
60612-1908
US

IV. Provider business mailing address

1440 W TAYLOR ST # 1105
CHICAGO IL
60607-4623
US

V. Phone/Fax

Practice location:
  • Phone: 773-999-6071
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: