Provider Demographics
NPI:1013186543
Name:WILBOURN, ASILI MAISHA (LVN)
Entity Type:Individual
Prefix:
First Name:ASILI
Middle Name:MAISHA
Last Name:WILBOURN
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3612 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-2106
Mailing Address - Country:US
Mailing Address - Phone:909-804-2702
Mailing Address - Fax:
Practice Address - Street 1:831 E ARROW HWY
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2535
Practice Address - Country:US
Practice Address - Phone:909-398-4383
Practice Address - Fax:909-398-0127
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA212323164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse