Provider Demographics
NPI:1053192484
Name:WILSON, VANEIQUA
Entity type:Individual
Prefix:
First Name:VANEIQUA
Middle Name:
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 1:3530 FRANCIS LEWIS BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1959
Mailing Address - Country:US
Mailing Address - Phone:718-939-0306
Mailing Address - Fax:
Practice Address - Street 1:3530 FRANCIS LEWIS BLVD STE 204
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-1959
Practice Address - Country:US
Practice Address - Phone:718-939-0306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist