Provider Demographics
NPI:1497408090
Name:WILSON, LOMETRIA
Entity Type:Individual
Prefix:
First Name:LOMETRIA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 SANDORRA RD
Mailing Address - Street 2:
Mailing Address - City:LATTA
Mailing Address - State:SC
Mailing Address - Zip Code:29565-5323
Mailing Address - Country:US
Mailing Address - Phone:843-616-8770
Mailing Address - Fax:843-433-8132
Practice Address - Street 1:108A E MAIN ST
Practice Address - Street 2:
Practice Address - City:LATTA
Practice Address - State:SC
Practice Address - Zip Code:29565-1617
Practice Address - Country:US
Practice Address - Phone:843-616-8770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 291U00000X, 332U00000X, 374U00000X, 376J00000X
SC42D2257730291U00000X
SC376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No251E00000XAgenciesHome Health
No291U00000XLaboratoriesClinical Medical Laboratory
No332U00000XSuppliersHome Delivered Meals
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker