Provider Demographics
NPI:1972107647
Name:WILSON, SHONDA
Entity type:Individual
Prefix:
First Name:SHONDA
Middle Name:
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:PO BOX 4507
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32802-4507
Mailing Address - Country:US
Mailing Address - Phone:689-777-1810
Mailing Address - Fax:321-218-5861
Practice Address - Street 1:344 ERON WAY
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-5802
Practice Address - Country:US
Practice Address - Phone:689-777-1810
Practice Address - Fax:321-218-5861
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide