Healthcare Provider Details

I. General information

NPI: 1366307985
Provider Name (Legal Business Name): KEIA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1081 BRADFORD RIDGE DR
LEESBURG FL
34748-9209
US

IV. Provider business mailing address

1081 BRADFORD RIDGE DR
LEESBURG FL
34748-9209
US

V. Phone/Fax

Practice location:
  • Phone: 352-217-3080
  • Fax:
Mailing address:
  • Phone: 352-217-3080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: