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General NPI Number Information
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NPI Number | 1669198511
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Entity Type | Individual
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Provider Name | TANEISHA EVETTE WILSON
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Gender | Female
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Dates
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Enumeration Date | 10/12/2022
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Last Update Date | 10/12/2022
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Provider Practice Location Address
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Address Line | 6771 RHODE ISLAND DR W
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City | JACKSONVILLE
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State | FL
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Zip | 32209-1435
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Country | US
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Telephone | 904-333-7351
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Fax |
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Provider Business Mailing Address
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Address Line | 6771 RHODE ISLAND DR W
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City | JACKSONVILLE
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State | FL
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Zip | 32209-1435
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Country | US
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Telephone | 904-333-7351
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 480
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 376J00000X
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Taxonomy Name | Homemaker
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License Number | 236090
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License Number State | FL
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