Provider Demographics
NPI:1659671444
Name:WILSON, LA TONYA (MSN, FNP-BC, NP-C)
Entity Type:Individual
Prefix:MS
First Name:LA TONYA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSN, FNP-BC, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 WILKINSON LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-6811
Mailing Address - Country:US
Mailing Address - Phone:803-225-5176
Mailing Address - Fax:
Practice Address - Street 1:6439 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1638
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC206993163W00000X
SC19664363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse