MEDICARE: LATASHA WILKERSON LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	2041559	KY

General Provider Information

NPI Number	:	1518103258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATASHA WILKERSON LPN

Provider Business Mailing Address
First Line	:	5979 DESERT STORM AVE
Second Line	:
City	:	FORT CAMPBELL
State	:	KY
Zip	:	42223-5585
Country	:	US
Telephone Number	:	270-956-0303
Fax Number	:

Provider Business Practice Location Address
First Line	:	5979 DESERT STORM AVE
Second Line	:
City	:	FORT CAMPBELL
State	:	KY
Zip	:	42223-5585
Country	:	US
Telephone Number	:	270-956-0303
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/31/2008
Last Update Date	:	12/31/2008

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