Provider Demographics
NPI:1760246615
Name:WILSON, KENISHA
Entity Type:Individual
Prefix:
First Name:KENISHA
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 1:310 FLEET ST
Mailing Address - Street 2:
Mailing Address - City:BRADDOCK
Mailing Address - State:PA
Mailing Address - Zip Code:15104-1153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 FLEET ST
Practice Address - Street 2:
Practice Address - City:BRADDOCK
Practice Address - State:PA
Practice Address - Zip Code:15104-1153
Practice Address - Country:US
Practice Address - Phone:412-952-1373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA18649374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula