Healthcare Provider Details

I. General information

NPI: 1780952580
Provider Name (Legal Business Name): LORETTA EVE WILSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORETTA EVE WILSON

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 03/25/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

488 W. MAIN STREET STE 101
VAN TX
75790-2608
US

IV. Provider business mailing address

488 W. MAIN STREET STE 101
VAN TX
75790-2608
US

V. Phone/Fax

Practice location:
  • Phone: 903-963-6850
  • Fax: 903-509-5835
Mailing address:
  • Phone: 903-963-6850
  • Fax: 903-509-5835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP121117
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: