Provider Demographics
NPI:1649720582
Name:WILSON, BONNIE B (LPN)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:B
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4645 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70127-3928
Mailing Address - Country:US
Mailing Address - Phone:504-308-3291
Mailing Address - Fax:504-309-8354
Practice Address - Street 1:1615 CANAL ST
Practice Address - Street 2:SUITE B
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2819
Practice Address - Country:US
Practice Address - Phone:504-308-3292
Practice Address - Fax:504-309-8354
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20120497164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse