Healthcare Provider Details

I. General information

NPI: 1003326794
Provider Name (Legal Business Name): WISTON ST JULIEN MHA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 NW 53RD ST STE 125
BOCA RATON FL
33487-8236
US

IV. Provider business mailing address

621 NW 53RD ST STE 125
BOCA RATON FL
33487-8236
US

V. Phone/Fax

Practice location:
  • Phone: 561-860-3094
  • Fax:
Mailing address:
  • Phone: 561-860-3094
  • Fax: 561-634-7438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number39969280
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: