Provider Demographics
NPI:1245677806
Name:WILSON, LAVONA CONSTANCIA (NP)
Entity type:Individual
Prefix:MRS
First Name:LAVONA
Middle Name:CONSTANCIA
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:467 KELLY ST SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-3006
Mailing Address - Country:US
Mailing Address - Phone:301-717-5997
Mailing Address - Fax:
Practice Address - Street 1:6120 ALABAMA HWY
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-2804
Practice Address - Country:US
Practice Address - Phone:706-935-6442
Practice Address - Fax:706-935-6441
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN208918363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily