Provider Demographics
NPI:1649890112
Name:WILKS, ROBERTA MASHEL (LVN)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:MASHEL
Last Name:WILKS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 SOUTHHAMPTON PLACE
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165
Mailing Address - Country:US
Mailing Address - Phone:903-253-4630
Mailing Address - Fax:
Practice Address - Street 1:109 SOUTHHAMPTON PLACE
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165
Practice Address - Country:US
Practice Address - Phone:903-253-4630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX147634164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse