Provider Demographics
NPI:1265082036
Name:WILSON, WELTHY NORIVA
Entity type:Individual
Prefix:
First Name:WELTHY
Middle Name:NORIVA
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-2541
Mailing Address - Country:US
Mailing Address - Phone:707-999-8305
Mailing Address - Fax:
Practice Address - Street 1:311 W WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2541
Practice Address - Country:US
Practice Address - Phone:707-999-8305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOTHEROtherCOMMUNITY CARE