Provider Demographics
NPI:1386372167
Name:WILSON, DEJANIQUE SHANICE
Entity type:Individual
Prefix:
First Name:DEJANIQUE
Middle Name:SHANICE
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 1:2337 PITTS PL SE APT 101
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-4969
Mailing Address - Country:US
Mailing Address - Phone:202-704-2218
Mailing Address - Fax:
Practice Address - Street 1:2338 PITTS PL SE APT 100
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-4986
Practice Address - Country:US
Practice Address - Phone:202-704-2218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide