Healthcare Provider Details

I. General information

NPI: 1497421119
Provider Name (Legal Business Name): TENELLE LYNN WILSON AP DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2021
Last Update Date: 08/22/2021
Certification Date: 08/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 CAPE CORAL PKWY E STE 10
CAPE CORAL FL
33904-8590
US

IV. Provider business mailing address

621 CAPE CORAL PKWY E STE 10
CAPE CORAL FL
33904-8590
US

V. Phone/Fax

Practice location:
  • Phone: 239-201-7907
  • Fax:
Mailing address:
  • Phone: 239-201-7907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP4141
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: