Provider Demographics
NPI:1992386080
Name:WILSON, ROSALYN SHANTAY
Entity Type:Individual
Prefix:
First Name:ROSALYN
Middle Name:SHANTAY
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 1:93 HUMAN SERVICES RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-7546
Mailing Address - Country:US
Mailing Address - Phone:864-833-0100
Mailing Address - Fax:
Practice Address - Street 1:93 HUMAN SERVICES RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7546
Practice Address - Country:US
Practice Address - Phone:864-833-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC218878163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health