Provider Demographics
NPI:1093550121
Name:WILSON, LATISHA
Entity type:Individual
Prefix:
First Name:LATISHA
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 1:1003 CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:DAINGERFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:75638-2215
Mailing Address - Country:US
Mailing Address - Phone:903-285-4332
Mailing Address - Fax:
Practice Address - Street 1:1003 CARPENTER ST
Practice Address - Street 2:
Practice Address - City:DAINGERFIELD
Practice Address - State:TX
Practice Address - Zip Code:75638-2215
Practice Address - Country:US
Practice Address - Phone:903-285-4332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-29
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty