Provider Demographics
NPI:1477225902
Name:WILSON ROBERTS, LATORI DIANE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:LATORI
Middle Name:DIANE
Last Name:WILSON ROBERTS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:LATORI
Other - Middle Name:DIANE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:PO BOX 211699
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-3699
Mailing Address - Country:US
Mailing Address - Phone:866-849-0692
Mailing Address - Fax:
Practice Address - Street 1:232 MARKET ST
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-3339
Practice Address - Country:US
Practice Address - Phone:866-849-0692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11040265363LF0000X
SC30615363LF0000X
KY4043239363LF0000X
OR10046480363LF0000X
COCAPN.0104600-C-NP363LF0000X
GAGAA-NP003696363LF0000X
OH0039494363LF0000X
MS904922363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily