Provider Demographics
NPI:1629849278
Name:MACON-WILSON, LATIJERA (CAMCT)
Entity Type:Individual
Prefix:
First Name:LATIJERA
Middle Name:
Last Name:MACON-WILSON
Suffix:
Gender:F
Credentials:CAMCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3969 4TH AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3165
Mailing Address - Country:US
Mailing Address - Phone:619-403-9024
Mailing Address - Fax:
Practice Address - Street 1:3969 4TH AVE STE 206
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3165
Practice Address - Country:US
Practice Address - Phone:619-403-9024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36520225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist