MEDICARE: KEIARRA MARQUEL 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1356971741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEIARRA MARQUEL WILSON

Provider Business Mailing Address
First Line	:	2622 WHITE CT
Second Line	:
City	:	COVINGTON
State	:	KY
Zip	:	41011-3950
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2622 WHITE CT
Second Line	:
City	:	COVINGTON
State	:	KY
Zip	:	41011-3950
Country	:	US
Telephone Number	:	513-696-2753
Fax Number	:

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

Provider Enumeration Date	:	01/24/2020
Last Update Date	:	01/24/2020

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