Provider Demographics
NPI:1003135617
Name:WILSON, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9906 YALE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-2158
Mailing Address - Country:US
Mailing Address - Phone:216-240-1705
Mailing Address - Fax:440-942-2025
Practice Address - Street 1:9906 YALE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-2158
Practice Address - Country:US
Practice Address - Phone:216-240-1705
Practice Address - Fax:440-942-2025
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400200120103376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide