Provider Demographics
NPI:1891192894
Name:WILSON, DWAYNE
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
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 1:24455 LAKE SHORE BLVD
Mailing Address - Street 2:APT. 1818
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-1273
Mailing Address - Country:US
Mailing Address - Phone:216-502-0246
Mailing Address - Fax:
Practice Address - Street 1:24455 LAKE SHORE BLVD
Practice Address - Street 2:APT. 1818
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44123-1273
Practice Address - Country:US
Practice Address - Phone:216-502-0246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN378820163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse