Provider Demographics
NPI:1003435322
Name:WILSON, TALISHA T
Entity Type:Individual
Prefix:
First Name:TALISHA
Middle Name:T
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAMA
Other - Middle Name:ANNIE'S
Other - Last Name:HOMECARE LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:9165 OTIS AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46216-2307
Mailing Address - Country:US
Mailing Address - Phone:317-657-9116
Mailing Address - Fax:
Practice Address - Street 1:9165 OTIS AVE STE 110
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-2307
Practice Address - Country:US
Practice Address - Phone:317-657-9116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1550684500172A00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172A00000XOther Service ProvidersDriver