Provider Demographics
NPI:1679813596
Name:SAVANNA V WILSON
Entity type:Organization
Organization Name:SAVANNA V WILSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:SAVANNA
Authorized Official - Middle Name:V
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-536-1914
Mailing Address - Street 1:707 E 242 STREET
Mailing Address - Street 2:6J
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10470
Mailing Address - Country:US
Mailing Address - Phone:845-536-1914
Mailing Address - Fax:
Practice Address - Street 1:707 E 242ND ST
Practice Address - Street 2:6J
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10470-1253
Practice Address - Country:US
Practice Address - Phone:845-536-1914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292513251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)