Healthcare Provider Details

I. General information

NPI: 1861800492
Provider Name (Legal Business Name): CORNELIA WILSON PMHCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2347 VINE ST
CINCINNATI OH
45219-1745
US

IV. Provider business mailing address

2347 VINE ST
CINCINNATI OH
45219-1745
US

V. Phone/Fax

Practice location:
  • Phone: 513-357-4602
  • Fax: 513-621-2350
Mailing address:
  • Phone: 513-357-4602
  • Fax: 513-621-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.126116-COA1
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberCOA.02677-NS
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: