Provider Demographics
NPI:1942631569
Name:WILSON, SHANNEL
Entity Type:Individual
Prefix:MS
First Name:SHANNEL
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:PO BOX 36522
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-0522
Mailing Address - Country:US
Mailing Address - Phone:567-249-7797
Mailing Address - Fax:
Practice Address - Street 1:5631 VIEWPOINTE DR APT G
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45213-2649
Practice Address - Country:US
Practice Address - Phone:567-249-7797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-07
Last Update Date:2013-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child