Provider Demographics
NPI:1114471273
Name:WILSON, CHEYENNE
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:
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 1:26836 EMMETT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3626
Mailing Address - Country:US
Mailing Address - Phone:313-717-0474
Mailing Address - Fax:
Practice Address - Street 1:26836 EMMETT ST
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-3626
Practice Address - Country:US
Practice Address - Phone:313-717-0474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other