Provider Demographics
NPI:1598334278
Name:WILSON, MICHELLE ANTOINETTE (RN, CLC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANTOINETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6552 SPRUCE DR E
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43217-1040
Mailing Address - Country:US
Mailing Address - Phone:614-289-8669
Mailing Address - Fax:
Practice Address - Street 1:6552 SPRUCE DR E
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43217-1040
Practice Address - Country:US
Practice Address - Phone:614-289-8669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.391106163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant