Provider Demographics
NPI:1104624790
Name:WILSON, LATONIA R
Entity type:Individual
Prefix:
First Name:LATONIA
Middle Name:R
Last Name:WILSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12620 SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-3044
Mailing Address - Country:US
Mailing Address - Phone:216-695-0014
Mailing Address - Fax:
Practice Address - Street 1:12620 SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44125-3044
Practice Address - Country:US
Practice Address - Phone:216-695-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator