Provider Demographics
NPI:1619715299
Name:WILSON, ANISA SHAKINHA
Entity type:Individual
Prefix:
First Name:ANISA
Middle Name:SHAKINHA
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 1:6520 SW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023-3818
Mailing Address - Country:US
Mailing Address - Phone:954-665-4143
Mailing Address - Fax:
Practice Address - Street 1:6520 SW 27TH ST
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33023-3818
Practice Address - Country:US
Practice Address - Phone:954-665-4143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician