Provider Demographics
NPI:1508590142
Name:WILSON, UNIKKA (NP-C)
Entity Type:Individual
Prefix:
First Name:UNIKKA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11138 DEL AMO BLVD STE 351
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90715-1103
Mailing Address - Country:US
Mailing Address - Phone:310-597-2688
Mailing Address - Fax:
Practice Address - Street 1:10565 CIVIC CENTER DR STE 165
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3854
Practice Address - Country:US
Practice Address - Phone:909-985-2211
Practice Address - Fax:909-985-2244
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020814363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner