Provider Demographics
NPI:1295235083
Name:WILSON, CHANE
Entity type:Individual
Prefix:
First Name:CHANE
Middle Name:
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 1:2202 STRATTON LN APT 16206
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-5453
Mailing Address - Country:US
Mailing Address - Phone:678-979-9171
Mailing Address - Fax:
Practice Address - Street 1:2202 STRATTON LN APT 16206
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-5453
Practice Address - Country:US
Practice Address - Phone:678-979-9171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-18
Last Update Date:2018-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX326695164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse