Healthcare Provider Details

I. General information

NPI: 1073421079
Provider Name (Legal Business Name): KERIONNA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6475 NEW HAMPSHIRE AVE STE 750
HYATTSVILLE MD
20783-3294
US

IV. Provider business mailing address

3107 ICEHOUSE PL
BRYANS ROAD MD
20616-7012
US

V. Phone/Fax

Practice location:
  • Phone: 240-468-9540
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: