Provider Demographics
NPI:1841866118
Name:WILSON, ALISA LANORA (LPN)
Entity type:Individual
Prefix:MISS
First Name:ALISA
Middle Name:LANORA
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 AVALON CIR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3855
Mailing Address - Country:US
Mailing Address - Phone:516-476-4284
Mailing Address - Fax:516-997-5336
Practice Address - Street 1:58 AVALON CIR
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3855
Practice Address - Country:US
Practice Address - Phone:516-476-4284
Practice Address - Fax:516-997-5336
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336632164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse