Provider Demographics
NPI:1306573589
Name:WILSON, CYNDRAANITA
Entity type:Individual
Prefix:MS
First Name:CYNDRAANITA
Middle Name:
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 1:1140 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-3141
Mailing Address - Country:US
Mailing Address - Phone:215-545-2273
Mailing Address - Fax:
Practice Address - Street 1:1140 S 15TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-3141
Practice Address - Country:US
Practice Address - Phone:215-545-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-06
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251G00000XAgenciesHospice Care, Community Based
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103944950-0001Medicaid