Provider Demographics
NPI:1538914635
Name:WILSON, CELINA R
Entity type:Individual
Prefix:
First Name:CELINA
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CELINA
Other - Middle Name:
Other - Last Name:VINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 S COUNTRY FAIR DR STE C
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-3064
Mailing Address - Country:US
Mailing Address - Phone:217-373-8200
Mailing Address - Fax:
Practice Address - Street 1:106 S COUNTRY FAIR DR STE C
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-3064
Practice Address - Country:US
Practice Address - Phone:217-373-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.106349164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse