Healthcare Provider Details

I. General information

NPI: 1710667399
Provider Name (Legal Business Name): LEQUITA MICHELLE WIGGINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4472 MISTY DAWN CT S
JACKSONVILLE FL
32277-1388
US

IV. Provider business mailing address

4472 MISTY DAWN CT S
JACKSONVILLE FL
32277-1388
US

V. Phone/Fax

Practice location:
  • Phone: 706-315-7863
  • Fax:
Mailing address:
  • Phone: 706-315-7863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9561258
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: