Provider Demographics
NPI:1558162719
Name:DONELY-WILSON, CHE-IA D (RN)
Entity type:Individual
Prefix:MRS
First Name:CHE-IA
Middle Name:D
Last Name:DONELY-WILSON
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 W 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-3905
Mailing Address - Country:US
Mailing Address - Phone:312-785-3863
Mailing Address - Fax:
Practice Address - Street 1:141 W 46TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-3905
Practice Address - Country:US
Practice Address - Phone:312-785-3863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.4622619163WH0500X
IL041.462619163WI0500X
IN28279273A163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WH0500XNursing Service ProvidersRegistered NurseHemodialysis
No163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Multi-Specialty