Provider Demographics
NPI:1255893434
Name:WILSON, NATASHA (HAIR LOSS SPECIALIST)
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:NATASHA
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1008 TIMBERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-2345
Mailing Address - Country:US
Mailing Address - Phone:601-347-6112
Mailing Address - Fax:
Practice Address - Street 1:959 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-4635
Practice Address - Country:US
Practice Address - Phone:601-347-6112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS515545174400000X
1744P3200X
MSH3T8J8P4246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management