Provider Demographics
NPI:1780952580
Name:WILSON, LORETTA EVE (FNP)
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:EVE
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LORETTA
Other - Middle Name:EVE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:488 W. MAIN STREET
Mailing Address - Street 2:STE 101
Mailing Address - City:VAN
Mailing Address - State:TX
Mailing Address - Zip Code:75790-2608
Mailing Address - Country:US
Mailing Address - Phone:903-963-6850
Mailing Address - Fax:903-509-5835
Practice Address - Street 1:488 W. MAIN STREET
Practice Address - Street 2:STE 101
Practice Address - City:VAN
Practice Address - State:TX
Practice Address - Zip Code:75790-2608
Practice Address - Country:US
Practice Address - Phone:903-963-6850
Practice Address - Fax:903-509-5835
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP121117363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner