Healthcare Provider Details

I. General information

NPI: 1619549979
Provider Name (Legal Business Name): LISA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PERKINS SQ
AKRON OH
44308-1063
US

IV. Provider business mailing address

2325 WYANDOTTE AVE
CUYAHOGA FALLS OH
44223-1048
US

V. Phone/Fax

Practice location:
  • Phone: 330-543-1000
  • Fax:
Mailing address:
  • Phone: 330-329-1504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number337486
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: