Individual
SHALISE TINA WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
245 E 680 S, CEDAR CITY, UT 84720-3593
(435) 867-7654
(435) 867-7699
Mailing address
245 E 680 S, CEDAR CITY, UT 84720-3593
(435) 867-7654
(435) 867-7699
Taxonomy
Speciality
Code
Description
License number
State
172V00000X
Community Health Worker
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1741000189085
PEHP
UT
Enumeration date
12/07/2017
Last updated
05/09/2024
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