MEDICARE: KAYINI 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	175T00000X	Peer Specialist	24-9142	WV

General Provider Information

NPI Number	:	1578383303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYINI WILSON

Provider Business Mailing Address
First Line	:	5635 MACCORKLE AVE SW APT 1A
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309-1059
Country	:	US
Telephone Number	:	681-317-5582
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 LINCOLN DR
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309-1834
Country	:	US
Telephone Number	:	681-205-8940
Fax Number	:

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

Provider Enumeration Date	:	10/16/2024
Last Update Date	:	10/16/2024

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