Individual
GLORIOUS LATRIC WILSON-REYNOLDS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CPNP
Contact information
Practice address
1509 STATE ST, LA PORTE, IN 46350-3115
(219) 324-3431
(219) 362-3802
Mailing address
2022 KELLE DR, CHESTERTON, IN 46304-8708
(219) 326-2312
(219) 326-2584
Taxonomy
Speciality
Code
Description
License number
State
363LP0200X
Pediatric Nurse Practitioner
209008737
IL
363LP0200X
Pediatric Nurse Practitioner
Primary
71005286A
IN
Other
Enumeration date
07/16/2012
Last updated
09/28/2020
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