Provider Demographics
NPI:1679248512
Name:WILBORN, MIA JAN'E
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:JAN'E
Last Name:WILBORN
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 1:1960 E COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:MINERAL RIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:44440-9408
Mailing Address - Country:US
Mailing Address - Phone:330-596-1042
Mailing Address - Fax:
Practice Address - Street 1:1960 E COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:MINERAL RIDGE
Practice Address - State:OH
Practice Address - Zip Code:44440-9408
Practice Address - Country:US
Practice Address - Phone:330-596-1042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2615030Medicaid