Provider Demographics
NPI:1700762309
Name:WILSON, KEYONNA N (HHA/CNA/QMA/LPN/RN)
Entity type:Individual
Prefix:
First Name:KEYONNA
Middle Name:N
Last Name:WILSON
Suffix:
Gender:F
Credentials:HHA/CNA/QMA/LPN/RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6030 E 42ND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-4910
Mailing Address - Country:US
Mailing Address - Phone:317-668-6535
Mailing Address - Fax:317-668-6535
Practice Address - Street 1:6030 E 42ND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-4910
Practice Address - Country:US
Practice Address - Phone:317-668-6535
Practice Address - Fax:317-668-6535
Is Sole Proprietor?:No
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27080699A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse