Provider Demographics
NPI:1619584752
Name:WILSON, SANDRA LYNN
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
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 1:411 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROMNEY
Mailing Address - State:WV
Mailing Address - Zip Code:26757-1530
Mailing Address - Country:US
Mailing Address - Phone:304-359-2349
Mailing Address - Fax:
Practice Address - Street 1:411 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ROMNEY
Practice Address - State:WV
Practice Address - Zip Code:26757-1530
Practice Address - Country:US
Practice Address - Phone:304-359-2349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant