Basic Information
| Provider Information | |||||||||
| NPI: | 1245677806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | LAVONA | ||||||||
| MiddleName: | CONSTANCIA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 467 KELLY ST SE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303123006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017175997 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6120 ALABAMA HWY | ||||||||
| Address2: | |||||||||
| City: | RINGGOLD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307362804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069356442 | ||||||||
| FaxNumber: | 7069356441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2013 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN208918 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.