Provider Demographics
NPI:1730849852
Name:WILSON, VICTORIA NICHOLE
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:NICHOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1041
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71049-1041
Mailing Address - Country:US
Mailing Address - Phone:318-575-9018
Mailing Address - Fax:
Practice Address - Street 1:1409 JACQUALINE STREET
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:LA
Practice Address - Zip Code:71049
Practice Address - Country:US
Practice Address - Phone:318-575-9018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3247Medicaid