Healthcare Provider Details

I. General information

NPI: 1942631569
Provider Name (Legal Business Name): MS. SHANNEL WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2013
Last Update Date: 12/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5631 VIEWPOINTE DR APT G
CINCINNATI OH
45213-2649
US

IV. Provider business mailing address

PO BOX 36522
CINCINNATI OH
45236-0522
US

V. Phone/Fax

Practice location:
  • Phone: 567-249-7797
  • Fax:
Mailing address:
  • Phone: 567-249-7797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: