Provider Demographics
NPI:1821431552
Name:WILSON, RONNELL M
Entity Type:Individual
Prefix:MR
First Name:RONNELL
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 W CHEYENNE AVE
Mailing Address - Street 2:APT 1106
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-4724
Mailing Address - Country:US
Mailing Address - Phone:951-250-1868
Mailing Address - Fax:
Practice Address - Street 1:5175 CAMINO AL NORTE
Practice Address - Street 2:SUIT 100
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-2407
Practice Address - Country:US
Practice Address - Phone:702-648-3913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner