Provider Demographics
NPI:1003292079
Name:IVERY-WILSON, MICHELLE JEANETTE (REGISTERED NURSE(RN))
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:JEANETTE
Last Name:IVERY-WILSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE(RN)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2914 MELBOURNE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417
Mailing Address - Country:US
Mailing Address - Phone:937-397-0334
Mailing Address - Fax:
Practice Address - Street 1:318 HOLLENCAMP AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-9029
Practice Address - Country:US
Practice Address - Phone:937-397-0334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH398412164W00000X
OHRN398412163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse