Healthcare Provider Details

I. General information

NPI: 1316865280
Provider Name (Legal Business Name): RAISA WILKENS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17555 NW 172ND AVE
ALACHUA FL
32615-0057
US

IV. Provider business mailing address

17555 NW 172ND AVE
ALACHUA FL
32615-0057
US

V. Phone/Fax

Practice location:
  • Phone: 561-570-0503
  • Fax:
Mailing address:
  • Phone: 561-570-0503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPSI45849
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: