Provider Demographics
NPI:1851846968
Name:WILSON, FAYOLA TRINEICE (LMT)
Entity Type:Individual
Prefix:
First Name:FAYOLA
Middle Name:TRINEICE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 FAGAN DRIVE
Mailing Address - Street 2:UNIT 6-B
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-5807
Mailing Address - Country:US
Mailing Address - Phone:985-318-0662
Mailing Address - Fax:
Practice Address - Street 1:906 FAGAN DRIVE
Practice Address - Street 2:UNIT 6-B
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-5807
Practice Address - Country:US
Practice Address - Phone:985-318-0662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA5480225700000X
LALMT5480302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No302R00000XManaged Care OrganizationsHealth Maintenance Organization