Provider Demographics
NPI:1033402268
Name:WILSON, SHANNON LOTESS (LPN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LOTESS
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168-34 127TH AVE
Mailing Address - Street 2:6A
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3108
Mailing Address - Country:US
Mailing Address - Phone:804-908-3835
Mailing Address - Fax:
Practice Address - Street 1:16834 127TH AVE
Practice Address - Street 2:6A
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-3148
Practice Address - Country:US
Practice Address - Phone:804-908-3835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-20
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305227164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6004868123234607060Medicaid