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General NPI Number Information
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NPI Number | 1780952580
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Entity Type | Individual
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Provider Name | LORETTA EVE WILSON FNP
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Gender | Female
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Dates
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Enumeration Date | 12/07/2011
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Last Update Date | 03/25/2022
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Provider Practice Location Address
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Address Line | 488 W. MAIN STREET STE 101
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City | VAN
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State | TX
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Zip | 75790-2608
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Country | US
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Telephone | 903-963-6850
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Fax | 903-509-5835
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Provider Business Mailing Address
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Address Line | 488 W. MAIN STREET STE 101
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City | VAN
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State | TX
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Zip | 75790-2608
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Country | US
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Telephone | 903-963-6850
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Fax | 903-509-5835
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | AP121117
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License Number State | TX
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