Provider Demographics
NPI:1780227173
Name:WILSON, LEON (HHA)
Entity Type:Individual
Prefix:MR
First Name:LEON
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 GOOD HOPE RD SE APT 402
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-5103
Mailing Address - Country:US
Mailing Address - Phone:202-577-2738
Mailing Address - Fax:
Practice Address - Street 1:2300 GOOD HOPE RD SE APT 402
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-5103
Practice Address - Country:US
Practice Address - Phone:202-577-2738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC14574374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC191018-000121Medicaid