Healthcare Provider Details

I. General information

NPI: 1801937859
Provider Name (Legal Business Name): ALICE R WILSON-EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2007
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MEMORIAL MEDICAL PKWY STE 308
DAYTONA BEACH FL
32117-5137
US

IV. Provider business mailing address

305 MEMORIAL MEDICAL PKWY STE 308
DAYTONA BEACH FL
32117-5137
US

V. Phone/Fax

Practice location:
  • Phone: 386-231-3600
  • Fax: 386-231-3602
Mailing address:
  • Phone: 386-231-3600
  • Fax: 386-231-3602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9121692
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: