MEDICARE: KEISHA CHALET WILSON HAIR LOSS SPECIALIST

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	1744P3200X	Prosthetics Case Management		NC

General Provider Information

NPI Number	:	1508590712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEISHA CHALET WILSON HAIR LOSS SPECIALIST

Provider Business Mailing Address
First Line	:	1005 BEATTIES FORD RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-5033
Country	:	US
Telephone Number	:	704-891-3723
Fax Number	:

Provider Business Practice Location Address
First Line	:	1005 BEATTIES FORD RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-5033
Country	:	US
Telephone Number	:	980-859-3002
Fax Number	:

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

Provider Enumeration Date	:	07/13/2022
Last Update Date	:	02/05/2026

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