Provider Demographics
NPI:1073737771
Name:WILEY, LOLISA DENISE (LPN)
Entity Type:Individual
Prefix:MS
First Name:LOLISA
Middle Name:DENISE
Last Name:WILEY
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 1:18420 GARDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-2629
Mailing Address - Country:US
Mailing Address - Phone:216-751-1083
Mailing Address - Fax:
Practice Address - Street 1:27107 KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:WARRENSVILLE HTS
Practice Address - State:OH
Practice Address - Zip Code:44128
Practice Address - Country:US
Practice Address - Phone:216-751-2840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-098381164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH107420131899Medicaid