Provider Demographics
NPI:1477225902
Name:WILSON, LATORI DIANE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LATORI
Middle Name:DIANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:LATORI
Other - Middle Name:DIANE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:6020 SHELBY RD
Mailing Address - Street 2:
Mailing Address - City:HERMANVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39086-9618
Mailing Address - Country:US
Mailing Address - Phone:601-529-3390
Mailing Address - Fax:
Practice Address - Street 1:6020 SHELBY RD
Practice Address - Street 2:
Practice Address - City:HERMANVILLE
Practice Address - State:MS
Practice Address - Zip Code:39086-9618
Practice Address - Country:US
Practice Address - Phone:601-529-3390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904922363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily