Provider Demographics
NPI:1912150707
Name:WILSON, SHARLENE ANTONETTE
Entity Type:Individual
Prefix:
First Name:SHARLENE
Middle Name:ANTONETTE
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 1:9715 64TH RD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2250
Mailing Address - Country:US
Mailing Address - Phone:718-459-5592
Mailing Address - Fax:718-459-6047
Practice Address - Street 1:9715 64TH RD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2250
Practice Address - Country:US
Practice Address - Phone:718-459-5592
Practice Address - Fax:718-459-6047
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282052164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse