Provider Demographics
NPI:1588326284
Name:WILSON, DEOSHANAY LAMYIA (DIPLOMA)
Entity type:Individual
Prefix:
First Name:DEOSHANAY
Middle Name:LAMYIA
Last Name:WILSON
Suffix:
Gender:F
Credentials:DIPLOMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4375 BOULDER HWY APT 346
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-3082
Mailing Address - Country:US
Mailing Address - Phone:702-801-4438
Mailing Address - Fax:
Practice Address - Street 1:4375 BOULDER HWY APT 346
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-3082
Practice Address - Country:US
Practice Address - Phone:702-801-4438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-10
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV21064517913747P1801X
NV000170044920632410863747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2003Medicaid
NVVNV713796566Medicaid