Provider Demographics
NPI:1538038682
Name:WILSON, DIEDRA MICHELLE (PMHNP-BC)
Entity type:Individual
Prefix:MISS
First Name:DIEDRA
Middle Name:MICHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38501 MENTOR AVE APT 250
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094-7734
Mailing Address - Country:US
Mailing Address - Phone:216-502-5313
Mailing Address - Fax:
Practice Address - Street 1:38501 MENTOR AVE APT 250
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-7734
Practice Address - Country:US
Practice Address - Phone:216-502-5313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-05
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0038687363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty