Provider Demographics
NPI:1871337220
Name:WILSON, MICHELLE LOUISE (LPN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LOUISE
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 1:913 BURNING SPRINGS CIR # 40223
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3609
Mailing Address - Country:US
Mailing Address - Phone:757-202-5433
Mailing Address - Fax:
Practice Address - Street 1:913 BURNING SPRINGS CIR # 40223
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-3609
Practice Address - Country:US
Practice Address - Phone:757-202-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2051538164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty