Healthcare Provider Details

I. General information

NPI: 1982258091
Provider Name (Legal Business Name): SHELBY LYNNE WILSON NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE # M61
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

9500 EUCLID AVE # M61
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 216-445-2224
  • Fax:
Mailing address:
  • Phone: 216-445-2224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.024992
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: