Healthcare Provider Details

I. General information

NPI: 1588071997
Provider Name (Legal Business Name): KIMBERLY WILKOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1565 SAXON BLVD
DELTONA FL
32725-5876
US

IV. Provider business mailing address

1200 LEXINGTON GREEN LN
SANFORD FL
32771-1013
US

V. Phone/Fax

Practice location:
  • Phone: 386-851-0901
  • Fax: 386-851-2426
Mailing address:
  • Phone: 407-688-0070
  • Fax: 407-688-0071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA24970
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: