Provider Demographics
NPI:1508590712
Name:WILSON BOURNE, KEISHA CHALET (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:CHALET
Last Name:WILSON BOURNE
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 BEATTIES FORD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-5033
Mailing Address - Country:US
Mailing Address - Phone:980-859-3002
Mailing Address - Fax:
Practice Address - Street 1:1005 BEATTIES FORD RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-5033
Practice Address - Country:US
Practice Address - Phone:980-859-3002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management