Provider Demographics
NPI:1205060191
Name:WIMBERLY, JANISA (RN)
Entity type:Individual
Prefix:
First Name:JANISA
Middle Name:
Last Name:WIMBERLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33464 SCHOENHERR RD STE 180
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-6392
Mailing Address - Country:US
Mailing Address - Phone:869-999-5971
Mailing Address - Fax:
Practice Address - Street 1:33464 SCHOENHERR RD STE 180
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-6392
Practice Address - Country:US
Practice Address - Phone:869-999-5971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704261913163W00000X
MI4703081901164W00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse