Provider Demographics
NPI:1013554765
Name:WILSON, TYEZHE' L
Entity Type:Individual
Prefix:
First Name:TYEZHE'
Middle Name:L
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 1:717 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44307-2021
Mailing Address - Country:US
Mailing Address - Phone:330-812-0723
Mailing Address - Fax:
Practice Address - Street 1:717 EDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307-2021
Practice Address - Country:US
Practice Address - Phone:330-812-0723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer