Provider Demographics
NPI:1164661278
Name:WILSON, CHANEL LENISE
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:LENISE
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 1:19501 MONTEREY AVE
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44119-1506
Mailing Address - Country:US
Mailing Address - Phone:216-338-1315
Mailing Address - Fax:
Practice Address - Street 1:19501 MONTEREY AVE
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44119-1506
Practice Address - Country:US
Practice Address - Phone:216-338-1315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.118035-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse