Provider Demographics
NPI:1689388456
Name:WILSON, TASHIONNA MABLE (CNA)
Entity Type:Individual
Prefix:
First Name:TASHIONNA
Middle Name:MABLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:876 W HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-3112
Mailing Address - Country:US
Mailing Address - Phone:614-398-1241
Mailing Address - Fax:
Practice Address - Street 1:876 W HERITAGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-3112
Practice Address - Country:US
Practice Address - Phone:614-398-1241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH601979320623376K00000X
376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide