Provider Demographics
NPI:1023592565
Name:WILSON, AVIS IRENE (PCA)
Entity type:Individual
Prefix:
First Name:AVIS
Middle Name:IRENE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:AVIS
Other - Middle Name:IRENE
Other - Last Name:CHAPLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2799 GAULEY TPKE,
Mailing Address - Street 2:
Mailing Address - City:FLATWOODS
Mailing Address - State:WV
Mailing Address - Zip Code:26621
Mailing Address - Country:US
Mailing Address - Phone:304-765-9576
Mailing Address - Fax:
Practice Address - Street 1:2799 GAULEY TPKE
Practice Address - Street 2:
Practice Address - City:FLATWOODS
Practice Address - State:WV
Practice Address - Zip Code:26621
Practice Address - Country:US
Practice Address - Phone:304-765-9576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810027594OtherPROVIDER ID