Provider Demographics
NPI:1245842897
Name:WILSON, SANDRA D (MS)
Entity type:Individual
Prefix:MISS
First Name:SANDRA
Middle Name:D
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5461 PORTMAN DR
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-8225
Mailing Address - Country:US
Mailing Address - Phone:317-419-7794
Mailing Address - Fax:
Practice Address - Street 1:5461 PORTMAN DR
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-8225
Practice Address - Country:US
Practice Address - Phone:317-413-9608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN230162951374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide