MEDICARE: SHENELLE WILSON

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	208800000X	Urology Physician	36843	AL
2	208800000X	Urology Physician	85818	GA

General Provider Information

NPI Number	:	1215283775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHENELLE WILSON

Provider Business Mailing Address
First Line	:	1021 W OAKLAND AVE STE 310
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-2192
Country	:	US
Telephone Number	:	423-302-6565
Fax Number	:

Provider Business Practice Location Address
First Line	:	2204 PAVILION DR STE 310
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37660-4653
Country	:	US
Telephone Number	:	423-246-4155
Fax Number	:

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

Provider Enumeration Date	:	08/01/2012
Last Update Date	:	09/13/2023

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Directions to “ SHENELLE WILSON ” Practice Location

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