MEDICARE: MS. SHEILA RENEA WILSON PERSONAL ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant		IL

General Provider Information

NPI Number	:	1144264102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHEILA RENEA WILSON PERSONAL ASSISTANT

Provider Business Mailing Address
First Line	:	433 MAPLEWOOD AVE
Second Line	:
City	:	CREVE COEUR
State	:	IL
Zip	:	61610-3206
Country	:	US
Telephone Number	:	309-698-8961
Fax Number	:

Provider Business Practice Location Address
First Line	:	5533 N GALENA RD
Second Line	:
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616-4461
Country	:	US
Telephone Number	:	309-282-2073
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	07/09/2007

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