Provider Demographics
NPI:1093941056
Name:WILSON, NICOLE SHAREE
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:SHAREE
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 1:4774 MUNSON ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3634
Mailing Address - Country:US
Mailing Address - Phone:330-494-0422
Mailing Address - Fax:
Practice Address - Street 1:1455 WESTFIELD AVE SW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-4235
Practice Address - Country:US
Practice Address - Phone:330-966-7347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4047111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor