Provider Demographics
NPI:1104267178
Name:WILSON, ATHINA KAY (LVN)
Entity type:Individual
Prefix:
First Name:ATHINA
Middle Name:KAY
Last Name:WILSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17121 ERWIN LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-5504
Mailing Address - Country:US
Mailing Address - Phone:714-614-8219
Mailing Address - Fax:
Practice Address - Street 1:17121 ERWIN LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5504
Practice Address - Country:US
Practice Address - Phone:714-614-8219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA263156164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse