Provider Demographics
NPI:1417076639
Name:WILSON, SHAWNTA JOLAN (RN)
Entity Type:Individual
Prefix:MRS
First Name:SHAWNTA
Middle Name:JOLAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MCCULLOUGH DR.
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-7803
Mailing Address - Country:US
Mailing Address - Phone:937-886-0194
Mailing Address - Fax:937-886-0194
Practice Address - Street 1:23 MCCULLOUGH DR.
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-7803
Practice Address - Country:US
Practice Address - Phone:937-886-0194
Practice Address - Fax:937-886-0194
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 330795163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2578554Medicaid