Provider Demographics
NPI:1215060405
Name:WILSON, GLORIA RENEE (STNA)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:RENEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4359 NORTHFIELD RD
Mailing Address - Street 2:APT.201A
Mailing Address - City:WARRENSVILLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44128-4676
Mailing Address - Country:US
Mailing Address - Phone:216-799-1095
Mailing Address - Fax:
Practice Address - Street 1:4359 NORTHFIELD RD
Practice Address - Street 2:APT.201A
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44128-4676
Practice Address - Country:US
Practice Address - Phone:216-799-1095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400211150203376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide