Provider Demographics
NPI:1922237619
Name:WILSON, CHERYL (RN)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:746 COUNTY ROAD 625 N
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:IL
Mailing Address - Zip Code:62468-4007
Mailing Address - Country:US
Mailing Address - Phone:217-849-3857
Mailing Address - Fax:217-849-3434
Practice Address - Street 1:200 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:IL
Practice Address - Zip Code:62468-1034
Practice Address - Country:US
Practice Address - Phone:217-849-3000
Practice Address - Fax:217-849-3434
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.139324302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization