Provider Demographics
NPI:1548904063
Name:SHIRLEY WILSON HEAVENLY HEALTHCARE
Entity type:Organization
Organization Name:SHIRLEY WILSON HEAVENLY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:CRAWFORD
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:904-487-3949
Mailing Address - Street 1:5105 BENNING RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-3610
Mailing Address - Country:US
Mailing Address - Phone:904-487-3949
Mailing Address - Fax:
Practice Address - Street 1:5105 BENNING RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-3610
Practice Address - Country:US
Practice Address - Phone:904-667-7962
Practice Address - Fax:904-580-5805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty