Provider Demographics
NPI:1124767975
Name:WILSON, FANTASIA DIOR
Entity type:Individual
Prefix:
First Name:FANTASIA
Middle Name:DIOR
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 1:1106 EASTERN AVE NE APT 102
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-4086
Mailing Address - Country:US
Mailing Address - Phone:240-234-2209
Mailing Address - Fax:
Practice Address - Street 1:2330 GOOD HOPE RD SE APT 1017
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-4148
Practice Address - Country:US
Practice Address - Phone:240-704-0745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant