Provider Demographics
NPI:1447462593
Name:WILSON, BONNIE LEE (LPN)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:LEE
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 1:1212 HANLEY RD W
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44904
Mailing Address - Country:US
Mailing Address - Phone:419-512-3377
Mailing Address - Fax:419-884-7368
Practice Address - Street 1:1212 HANLEY RD W
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44904
Practice Address - Country:US
Practice Address - Phone:419-512-3379
Practice Address - Fax:419-884-7368
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN029260164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2270368Medicaid