Provider Demographics
NPI:1699250225
Name:WILSON, DEMETIRUS LEGAIL
Entity type:Individual
Prefix:
First Name:DEMETIRUS
Middle Name:LEGAIL
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 1:3584 BENNETT RD
Mailing Address - Street 2:
Mailing Address - City:EAST RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37412-1167
Mailing Address - Country:US
Mailing Address - Phone:423-635-8738
Mailing Address - Fax:
Practice Address - Street 1:73 MALLARD HL
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-4964
Practice Address - Country:US
Practice Address - Phone:423-503-4507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN066777374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN474763392OtherCITY OF CHATTANOOGA