1053471524 NPI number — MRS. HEATHER RENEE' WILSON L.P.N

Table of content: MRS. HEATHER RENEE' WILSON L.P.N (NPI 1053471524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053471524 NPI number — MRS. HEATHER RENEE' WILSON L.P.N

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
HEATHER
Provider Middle Name:
RENEE'
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
L.P.N
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053471524
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
365 FOX HILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHILLICOTHEE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45601-7710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-642-2222
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1476 LANCASTER PIKE
Provider Second Line Business Practice Location Address:
LOT 28
Provider Business Practice Location Address City Name:
CIRCLEVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43113-9487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-474-5908
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  PN104493 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2553759 . This is a "ODJFS INDEPENDENT PROVIDE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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