Provider Demographics
NPI:1811408024
Name:WILSON, LATOYA TAMARA MONIQUE (DNP)
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:TAMARA MONIQUE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592 ROCKAWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-5539
Mailing Address - Country:US
Mailing Address - Phone:347-345-5000
Mailing Address - Fax:718-345-5794
Practice Address - Street 1:592 ROCKAWAY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-5539
Practice Address - Country:US
Practice Address - Phone:718-345-5000
Practice Address - Fax:718-345-5794
Is Sole Proprietor?:No
Enumeration Date:2017-10-14
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341281363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04940070Medicaid