Provider Demographics
NPI:1093912404
Name:WILSON, SHIRLEY CRAWFORD
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:CRAWFORD
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 BENNING RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-3610
Mailing Address - Country:US
Mailing Address - Phone:904-487-3949
Mailing Address - Fax:904-580-5805
Practice Address - Street 1:5105 BENNING RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-3610
Practice Address - Country:US
Practice Address - Phone:904-487-3949
Practice Address - Fax:904-580-5805
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL238327374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024749500Medicaid