Provider Demographics
NPI:1497462097
Name:WILSON, CORA
Entity Type:Individual
Prefix:
First Name:CORA
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 1:1827 S 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-3011
Mailing Address - Country:US
Mailing Address - Phone:708-299-0746
Mailing Address - Fax:
Practice Address - Street 1:1827 S 16TH AVE
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-3011
Practice Address - Country:US
Practice Address - Phone:708-299-0746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherTECHNICIAN/HOMECARE