Provider Demographics
NPI:1619028057
Name:WILSON, SONJIA
Entity Type:Individual
Prefix:
First Name:SONJIA
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 1:14102 KORNBLUM AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-8668
Mailing Address - Country:US
Mailing Address - Phone:310-650-1275
Mailing Address - Fax:
Practice Address - Street 1:14102 KORNBLUM AVE APT 7
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-8668
Practice Address - Country:US
Practice Address - Phone:310-650-1275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN187774164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEPS015450Medicaid
CAEPS015450Medicaid