Provider Demographics
NPI:1437722949
Name:MOORE- WILSON, WANDA TERRELL (MB&C, CNA,MOA)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:TERRELL
Last Name:MOORE- WILSON
Suffix:
Gender:F
Credentials:MB&C, CNA,MOA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5612 S WABASH AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1155
Mailing Address - Country:US
Mailing Address - Phone:312-481-3779
Mailing Address - Fax:
Practice Address - Street 1:5612 S WABASH AVE # APTY5
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1155
Practice Address - Country:US
Practice Address - Phone:312-481-3779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2023-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL247000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information