Healthcare Provider Details

I. General information

NPI: 1982517132
Provider Name (Legal Business Name): DALLAS WILFONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 HIBISCUS ST
VACAVILLE CA
95687-8299
US

IV. Provider business mailing address

348 HIBISCUS ST
VACAVILLE CA
95687-8299
US

V. Phone/Fax

Practice location:
  • Phone: 225-715-1149
  • Fax:
Mailing address:
  • Phone: 225-715-1149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number29425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: