Provider Demographics
NPI:1699535914
Name:WILSON, SEDONA SOWELL (RDN)
Entity type:Individual
Prefix:MS
First Name:SEDONA
Middle Name:SOWELL
Last Name:WILSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 SECESSIONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-8236
Mailing Address - Country:US
Mailing Address - Phone:717-339-9935
Mailing Address - Fax:
Practice Address - Street 1:1513 SECESSIONVILLE RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-8236
Practice Address - Country:US
Practice Address - Phone:717-339-9935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD006815133V00000X
SC2755133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered