Provider Demographics
NPI:1023388923
Name:WILSON, AMBER TANISHA (CPHT)
Entity Type:Individual
Prefix:MS
First Name:AMBER
Middle Name:TANISHA
Last Name:WILSON
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7070 TOMAHAWK TRL
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-4806
Mailing Address - Country:US
Mailing Address - Phone:614-517-9587
Mailing Address - Fax:
Practice Address - Street 1:7070 TOMAHAWK TRL
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-4806
Practice Address - Country:US
Practice Address - Phone:614-517-9587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5101-0701-0102-808247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH45-2758598Medicaid
OH45-2758598Medicaid