Provider Demographics
NPI:1053471524
Name:WILSON, HEATHER RENEE' (LPN)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:RENEE'
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 1:365 FOX HILL DR
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-7710
Mailing Address - Country:US
Mailing Address - Phone:740-642-2222
Mailing Address - Fax:
Practice Address - Street 1:1476 LANCASTER PIKE
Practice Address - Street 2:LOT 28
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-9487
Practice Address - Country:US
Practice Address - Phone:740-474-5908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN104493164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2553759OtherODJFS INDEPENDENT PROVIDE