Provider Demographics
NPI:1912223579
Name:WILSON, ANESTRA LATSHA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:ANESTRA
Middle Name:LATSHA
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:ANESTRA
Other - Middle Name:LATSHA
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:10531 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-2727
Mailing Address - Country:US
Mailing Address - Phone:216-322-7557
Mailing Address - Fax:
Practice Address - Street 1:10531 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-2727
Practice Address - Country:US
Practice Address - Phone:216-322-7557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-130198-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse