Provider Demographics
NPI:1942047824
Name:WILSON, TARAH LANIECE (LVN)
Entity type:Individual
Prefix:
First Name:TARAH
Middle Name:LANIECE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 E YOSEMITE AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-9167
Mailing Address - Country:US
Mailing Address - Phone:209-724-5413
Mailing Address - Fax:
Practice Address - Street 1:2351 LANCE ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-3739
Practice Address - Country:US
Practice Address - Phone:209-303-6347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA691867164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse