MEDICARE: CARRIE SUE 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	376J00000X	Homemaker

General Provider Information

NPI Number	:	1790453470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARRIE SUE WILSON

Provider Business Mailing Address
First Line	:	4308 LESTON AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45424-5945
Country	:	US
Telephone Number	:	937-207-1268
Fax Number	:

Provider Business Practice Location Address
First Line	:	4308 LESTON AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45424-5945
Country	:	US
Telephone Number	:	937-207-1268
Fax Number	:

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

Provider Enumeration Date	:	08/30/2021
Last Update Date	:	05/31/2024

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Directions to “ CARRIE SUE WILSON ” Practice Location

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