Provider Demographics
NPI:1669198511
Name:WILSON, TANEISHA EVETTE
Entity type:Individual
Prefix:
First Name:TANEISHA
Middle Name:EVETTE
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 1:6771 RHODE ISLAND DR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-1435
Mailing Address - Country:US
Mailing Address - Phone:904-333-7351
Mailing Address - Fax:
Practice Address - Street 1:6771 RHODE ISLAND DR W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-1435
Practice Address - Country:US
Practice Address - Phone:904-333-7351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL480251E00000X
FL236090376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No251E00000XAgenciesHome Health