Provider Demographics
NPI:1093904427
Name:WILSON, ELIZABETH R (LPN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
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 1:624 MARKET AVE. N
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1017
Mailing Address - Country:US
Mailing Address - Phone:330-493-4553
Mailing Address - Fax:330-493-3761
Practice Address - Street 1:624 MARKET AVE. N.
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702-1017
Practice Address - Country:US
Practice Address - Phone:330-493-4553
Practice Address - Fax:330-493-3761
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN095547101YM0800X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health