Healthcare Provider Details

I. General information

NPI: 1801730924
Provider Name (Legal Business Name): SHAWNEE SIMONE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2026
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 E 105TH ST LOWR
CLEVELAND OH
44104-5644
US

IV. Provider business mailing address

3434 E 105TH ST LOWR
CLEVELAND OH
44104-5644
US

V. Phone/Fax

Practice location:
  • Phone: 216-288-5757
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: