MEDICARE: TRENISE RALYNN WILSON

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	372600000X	Adult Companion
2	3747A0650X	Attendant Care Provider
3	376J00000X	Homemaker
4	3747P1801X	Personal Care Attendant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2105704841	OTHER	NV	IDENTIFICATION CARD

General Provider Information

NPI Number	:	1144738402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRENISE RALYNN WILSON

Provider Business Mailing Address
First Line	:	3700 E BONANZA RD APT 2119
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-2193
Country	:	US
Telephone Number	:	323-335-8124
Fax Number	:

Provider Business Practice Location Address
First Line	:	3700 E BONANZA RD APT 2119
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-2193
Country	:	US
Telephone Number	:	323-335-8124
Fax Number	:

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

Provider Enumeration Date	:	01/19/2018
Last Update Date	:	01/19/2018

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