Provider Demographics
NPI:1245080092
Name:WILSON, KEYVONIA (PHLEBOTOMY)
Entity type:Individual
Prefix:
First Name:KEYVONIA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHLEBOTOMY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 BISHOPS WAY STE 105
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-6249
Mailing Address - Country:US
Mailing Address - Phone:414-732-8890
Mailing Address - Fax:
Practice Address - Street 1:120 BISHOPS WAY STE 105
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6249
Practice Address - Country:US
Practice Address - Phone:414-732-8890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WINPCN-169866402246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy