Provider Demographics
NPI:1285490458
Name:WILSON, LYNNETTE S
Entity type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYNNETTE
Other - Middle Name:S
Other - Last Name:CECIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:NORTH LAWRENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44666-0026
Mailing Address - Country:US
Mailing Address - Phone:330-412-8066
Mailing Address - Fax:
Practice Address - Street 1:4150 ALABAMA AVE. N.W.
Practice Address - Street 2:
Practice Address - City:NORTH LAWRENCE
Practice Address - State:OH
Practice Address - Zip Code:44666
Practice Address - Country:US
Practice Address - Phone:330-412-8066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No376J00000XNursing Service Related ProvidersHomemaker