Provider Demographics
NPI:1184014052
Name:WILSON, NETRENA
Entity Type:Individual
Prefix:
First Name:NETRENA
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:PO BOX 705
Mailing Address - Street 2:
Mailing Address - City:CLARCONA
Mailing Address - State:FL
Mailing Address - Zip Code:32710-0705
Mailing Address - Country:US
Mailing Address - Phone:863-617-9355
Mailing Address - Fax:877-797-7978
Practice Address - Street 1:1293 S MCADOO AVE
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-6847
Practice Address - Country:US
Practice Address - Phone:863-617-9355
Practice Address - Fax:877-797-7978
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker