Individual
MISS CHONDRA JEMISE WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
COSMETOLOGIST
Contact information
Practice address
1696 LOMOND ST STE 201, WINSTON SALEM, NC 27127-2741
(757) 289-2020
Mailing address
1696 LOMOND ST STE 201, WINSTON SALEM, NC 27127-2741
(757) 289-2020
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
NC
1744P3200X
Prosthetics Case Management
—
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
C63644
COSMETOLOGY LICENSE
NC
Enumeration date
07/15/2020
Last updated
01/01/2024
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