Healthcare Provider Details

I. General information

NPI: 1982208237
Provider Name (Legal Business Name): AUDRANAY SHAVONE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2020
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 STATE ROAD 60 E
LAKE WALES FL
33853-4322
US

IV. Provider business mailing address

433 FISH HAWK DR
WINTER HAVEN FL
33884-4173
US

V. Phone/Fax

Practice location:
  • Phone: 863-275-1102
  • Fax:
Mailing address:
  • Phone: 863-326-3050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: