Provider Demographics
NPI:1659900611
Name:WILSON, SHALOM TAHNEE (LPN)
Entity Type:Individual
Prefix:MR
First Name:SHALOM
Middle Name:TAHNEE
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SHALOM WILSON
Mailing Address - Street 2:118 PINE STREET
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14445
Mailing Address - Country:US
Mailing Address - Phone:585-329-4306
Mailing Address - Fax:
Practice Address - Street 1:SHALOMWILSON36@GMAIL.COM
Practice Address - Street 2:118 PINE STREET
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14445
Practice Address - Country:US
Practice Address - Phone:585-329-4306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337636164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse