Healthcare Provider Details

I. General information

NPI: 1306573589
Provider Name (Legal Business Name): MS. CYNDRAANITA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2022
Last Update Date: 08/06/2022
Certification Date: 08/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 S 15TH ST
PHILADELPHIA PA
19146-3141
US

IV. Provider business mailing address

1140 S 15TH ST
PHILADELPHIA PA
19146-3141
US

V. Phone/Fax

Practice location:
  • Phone: 215-545-2273
  • Fax:
Mailing address:
  • Phone: 215-545-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: