Provider Demographics
NPI:1619549979
Name:WILSON, LISA
Entity Type:Individual
Prefix:
First Name:LISA
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 1:2325 WYANDOTTE AVE
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223-1048
Mailing Address - Country:US
Mailing Address - Phone:330-329-1504
Mailing Address - Fax:
Practice Address - Street 1:1 PERKINS SQ
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44308-1063
Practice Address - Country:US
Practice Address - Phone:330-543-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH337486363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical CareGroup - Single Specialty