Provider Demographics
NPI:1871168252
Name:WILSON, CONNIE T
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:T
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 1:13302 BENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-4606
Mailing Address - Country:US
Mailing Address - Phone:216-256-6101
Mailing Address - Fax:
Practice Address - Street 1:13302 BENWOOD AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-4606
Practice Address - Country:US
Practice Address - Phone:216-256-6101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide