Provider Demographics
NPI:1114765047
Name:WILSON, LATOYA RENEE (CEO)
Entity type:Individual
Prefix:
First Name:LATOYA
Middle Name:RENEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
Other - First Name:LATOYA
Other - Middle Name:RENEE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CEO
Mailing Address - Street 1:4114 N IRVINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-4772
Mailing Address - Country:US
Mailing Address - Phone:317-200-6078
Mailing Address - Fax:
Practice Address - Street 1:4114 N IRVINGTON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-4772
Practice Address - Country:US
Practice Address - Phone:317-200-6078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN24-017002-1372600000X, 3747P1801X, 376J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker