Healthcare Provider Details

I. General information

NPI: 1265357990
Provider Name (Legal Business Name): TANESHA WILSON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S HARBOR CITY BLVD STE 401
MELBOURNE FL
32901-1389
US

IV. Provider business mailing address

4195 HIELD RD NW
PALM BAY FL
32907-6310
US

V. Phone/Fax

Practice location:
  • Phone: 321-259-1662
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11049810
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: