Provider Demographics
NPI:1770731481
Name:WILSON, SHAWNEEN (LYMPHEDEMA THERAPIST)
Entity type:Individual
Prefix:
First Name:SHAWNEEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LYMPHEDEMA THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:NM
Mailing Address - Zip Code:88043-0034
Mailing Address - Country:US
Mailing Address - Phone:575-537-2867
Mailing Address - Fax:
Practice Address - Street 1:114 W 11TH ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5136
Practice Address - Country:US
Practice Address - Phone:575-388-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NM1627224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant