Provider Demographics
NPI:1700370764
Name:WILSON, SHANTA RENA
Entity Type:Individual
Prefix:
First Name:SHANTA
Middle Name:RENA
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 1:128 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334-2826
Mailing Address - Country:US
Mailing Address - Phone:318-437-7157
Mailing Address - Fax:318-437-7158
Practice Address - Street 1:128 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334-2826
Practice Address - Country:US
Practice Address - Phone:318-437-7157
Practice Address - Fax:318-437-7158
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator