Provider Demographics
NPI:1073167185
Name:WILSON, SHYEASHA TANIKA (APRN-BC, PMHNP-BC)
Entity type:Individual
Prefix:MISS
First Name:SHYEASHA
Middle Name:TANIKA
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN-BC, PMHNP-BC
Other - Prefix:
Other - First Name:SHY
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN-BC, PMHNP-BC
Mailing Address - Street 1:1911 GADSDEN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-6400
Mailing Address - Country:US
Mailing Address - Phone:803-254-9767
Mailing Address - Fax:
Practice Address - Street 1:1911 GADSDEN ST STE 204
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-6400
Practice Address - Country:US
Practice Address - Phone:803-254-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC104416163WP0808X
SC23783363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty