Basic Information
Provider Information | |||||||||
NPI: | 1083878318 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILSON | ||||||||
FirstName: | LATRELLE | ||||||||
MiddleName: | ZORN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSC CCC A | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ZORN | ||||||||
OtherFirstName: | LATRELLE | ||||||||
OtherMiddleName: | BEATRICE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MSC CCC A | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2163 NORMANDIE DRIVE | ||||||||
Address2: |   | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361112750 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3342841870 | ||||||||
FaxNumber: | 3342842112 | ||||||||
Practice Location | |||||||||
Address1: | 2163 NORMANDIE DRIVE | ||||||||
Address2: |   | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361112750 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3342841870 | ||||||||
FaxNumber: | 3342842112 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2008 | ||||||||
LastUpdateDate: | 03/11/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | ASHA01121390 |   | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
No ID Information.