Provider Demographics
NPI:1689977555
Name:WILKES, TALISA LACHELLE (RN)
Entity Type:Individual
Prefix:MRS
First Name:TALISA
Middle Name:LACHELLE
Last Name:WILKES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-4618
Mailing Address - Country:US
Mailing Address - Phone:631-647-2645
Mailing Address - Fax:
Practice Address - Street 1:1008 LAKE DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-4618
Practice Address - Country:US
Practice Address - Phone:631-647-2645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY634239-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse