Provider Demographics
NPI:1720683014
Name:WILSON, DEBRA LYNN (DODD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:DODD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14880 GAR HWY
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-9567
Mailing Address - Country:US
Mailing Address - Phone:440-286-5895
Mailing Address - Fax:
Practice Address - Street 1:14880 GAR HWY
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-9567
Practice Address - Country:US
Practice Address - Phone:440-286-5895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH347E00000X, 376J00000X
OH2800688385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No347E00000XTransportation ServicesTransportation Broker
No385H00000XRespite Care FacilityRespite Care