Provider Demographics
NPI:1407002603
Name:WILSON, LORETTA SUE (NP)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:SUE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LORETTA
Other - Middle Name:SUE
Other - Last Name:HENSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1019 CUMBERLAND FALLS HWY
Mailing Address - Street 2:SUITE B201
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2735
Mailing Address - Country:US
Mailing Address - Phone:606-526-9005
Mailing Address - Fax:606-526-8606
Practice Address - Street 1:39 CUMBERLAND GAP PLZ
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:KY
Practice Address - Zip Code:40734-4536
Practice Address - Country:US
Practice Address - Phone:606-526-9005
Practice Address - Fax:606-526-8606
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005770363L00000X
KY1083291363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100089740Medicaid