Provider Demographics
NPI:1952035818
Name:WILSON, KIARA DANIELLE (DRIVER)
Entity Type:Individual
Prefix:
First Name:KIARA
Middle Name:DANIELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DRIVER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BELLWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60104-2233
Mailing Address - Country:US
Mailing Address - Phone:708-488-6667
Mailing Address - Fax:
Practice Address - Street 1:3207 ADAMS ST
Practice Address - Street 2:
Practice Address - City:BELLWOOD
Practice Address - State:IL
Practice Address - Zip Code:60104-2233
Practice Address - Country:US
Practice Address - Phone:708-488-6667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILW425-5048-9626172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver