Healthcare Provider Details

I. General information

NPI: 1962116624
Provider Name (Legal Business Name): ISABELLE LORANE WILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

IV. Provider business mailing address

3200 S UNIVERSITY DR
DAVIE FL
33328-2018
US

V. Phone/Fax

Practice location:
  • Phone: 863-687-1100
  • Fax:
Mailing address:
  • Phone: 954-262-1250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9119390
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: