Healthcare Provider Details

I. General information

NPI: 1801433792
Provider Name (Legal Business Name): SANYELLE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANYELLE SANDUSKY

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 W 11TH AVE STE 200
EUGENE OR
97402-3871
US

IV. Provider business mailing address

941 W 7TH AVE
EUGENE OR
97402-4634
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-2688
  • Fax:
Mailing address:
  • Phone: 541-735-6345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: