Provider Demographics
NPI:1053027482
Name:WILSON, VENESSA NACOLE
Entity type:Individual
Prefix:
First Name:VENESSA
Middle Name:NACOLE
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 1:7819 BLUEBONNET BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-2836
Mailing Address - Country:US
Mailing Address - Phone:225-335-8652
Mailing Address - Fax:
Practice Address - Street 1:7819 BLUEBONNET BLVD STE C
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-2836
Practice Address - Country:US
Practice Address - Phone:225-335-8652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA419152335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier