Provider Demographics
NPI:1194360396
Name:WILSON, YAMIKA SHANTELL
Entity type:Individual
Prefix:
First Name:YAMIKA
Middle Name:SHANTELL
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 1:3421 SELLERS ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38127-5230
Mailing Address - Country:US
Mailing Address - Phone:901-652-6102
Mailing Address - Fax:
Practice Address - Street 1:3421 SELLERS ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38127-5230
Practice Address - Country:US
Practice Address - Phone:901-652-6102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN180004860343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)