Provider Demographics
NPI:1396576724
Name:WILSON, TYKIESHA MCDANIEL (FNP)
Entity type:Individual
Prefix:MS
First Name:TYKIESHA
Middle Name:MCDANIEL
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4944 GREENSBORO RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:VA
Mailing Address - Zip Code:24148-3390
Mailing Address - Country:US
Mailing Address - Phone:276-638-0787
Mailing Address - Fax:
Practice Address - Street 1:4944 GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:VA
Practice Address - Zip Code:24148-3390
Practice Address - Country:US
Practice Address - Phone:276-956-1629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024192215363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily