MEDICARE: TROYNECIA BRENEE 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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1902525009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TROYNECIA BRENEE WILSON

Provider Business Mailing Address
First Line	:	1105 ISLAND PARK BLVD APT 1007
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-4777
Country	:	US
Telephone Number	:	318-401-7632
Fax Number	:

Provider Business Practice Location Address
First Line	:	1105 ISLAND PARK BLVD APT 1007
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-4777
Country	:	US
Telephone Number	:	318-401-7632
Fax Number	:

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

Provider Enumeration Date	:	08/23/2022
Last Update Date	:	08/23/2022

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