Healthcare Provider Details

I. General information

NPI: 1285490458
Provider Name (Legal Business Name): LYNNETTE S WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LYNNETTE S CECIL

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 ALABAMA AVE. N.W.
NORTH LAWRENCE OH
44666
US

IV. Provider business mailing address

PO BOX 26
NORTH LAWRENCE OH
44666-0026
US

V. Phone/Fax

Practice location:
  • Phone: 330-412-8066
  • Fax:
Mailing address:
  • Phone: 330-412-8066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: