Provider Demographics
NPI:1720408040
Name:WILSON, MOYOHOENA
Entity Type:Individual
Prefix:
First Name:MOYOHOENA
Middle Name:
Last Name:WILSON
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 1:7 JEFFERSON PL
Mailing Address - Street 2:D1
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-1972
Mailing Address - Country:US
Mailing Address - Phone:914-318-5818
Mailing Address - Fax:
Practice Address - Street 1:7 JEFFERSON PL
Practice Address - Street 2:D1
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-1972
Practice Address - Country:US
Practice Address - Phone:914-318-5818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30759-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse