Provider Demographics
NPI:1982031944
Name:WILSON, JOHN FORREST III (BS, LPN)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:FORREST
Last Name:WILSON
Suffix:III
Gender:M
Credentials:BS, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 KETCHAM ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2124
Mailing Address - Country:US
Mailing Address - Phone:937-369-6966
Mailing Address - Fax:
Practice Address - Street 1:412 KETCHAM ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:OH
Practice Address - Zip Code:45431-2124
Practice Address - Country:US
Practice Address - Phone:937-369-6966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH152422164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse