Provider Demographics
NPI:1679014997
Name:WILSON, NICOLE LYNN (STNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2054 MAGEE ST
Mailing Address - Street 2:DOWN
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-5238
Mailing Address - Country:US
Mailing Address - Phone:216-849-1895
Mailing Address - Fax:
Practice Address - Street 1:2054 MAGEE ST
Practice Address - Street 2:DOWN
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-5238
Practice Address - Country:US
Practice Address - Phone:216-849-1895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401835840316376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide