Provider Demographics
NPI:1376898320
Name:WILSON-REYNOLDS, GLORIOUS LATRIC (CPNP)
Entity Type:Individual
Prefix:
First Name:GLORIOUS
Middle Name:LATRIC
Last Name:WILSON-REYNOLDS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:1509 STATE ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3115
Practice Address - Country:US
Practice Address - Phone:219-324-3431
Practice Address - Fax:219-362-3802
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008737363LP0200X
IN71005286A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics