Provider Demographics
NPI:1922620459
Name:WILSON, LATOSHA
Entity Type:Individual
Prefix:
First Name:LATOSHA
Middle Name:
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 1:3209 W RIGGIN RD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-1032
Mailing Address - Country:US
Mailing Address - Phone:765-400-8609
Mailing Address - Fax:
Practice Address - Street 1:3209 W RIGGIN RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-1032
Practice Address - Country:US
Practice Address - Phone:765-400-8609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171W00000XOther Service ProvidersContractor