Healthcare Provider Details

I. General information

NPI: 1063803575
Provider Name (Legal Business Name): SHEILA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5651 ALENLON WAY
MOUNT DORA FL
32757-8041
US

IV. Provider business mailing address

105 ROTH CT
FORT KNOX KY
40121-3507
US

V. Phone/Fax

Practice location:
  • Phone: 410-507-6854
  • Fax:
Mailing address:
  • Phone: 410-507-6854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN5206429
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMCAP.0101036
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: