Provider Demographics
NPI:1801536891
Name:WILSON, LAKEISHA (FNP-C)
Entity type:Individual
Prefix:
First Name:LAKEISHA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 ROOSEVELT CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-2421
Mailing Address - Country:US
Mailing Address - Phone:601-927-5002
Mailing Address - Fax:
Practice Address - Street 1:1806 SIMPSON HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-5391
Practice Address - Country:US
Practice Address - Phone:601-439-1420
Practice Address - Fax:601-439-1421
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF03220713363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily