Provider Demographics
NPI:1568817922
Name:WILSON, LARIE
Entity Type:Individual
Prefix:
First Name:LARIE
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 1:2221 SAN SIMEON DR
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75181-4646
Mailing Address - Country:US
Mailing Address - Phone:214-434-6218
Mailing Address - Fax:
Practice Address - Street 1:2221 SAN SIMEON DR
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75181-4646
Practice Address - Country:US
Practice Address - Phone:214-434-6218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-04
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant