=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871381442
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDY LEE WILSON LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2025
-----------------------------------------------------
Last Update Date | 04/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2781 OSBORN DR
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86406-8629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-505-5552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 418 N MOONLIGHT DR
-----------------------------------------------------
City | PARKER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85344-4110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-575-2982
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 273193
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------