Healthcare Provider Details

I. General information

NPI: 1235323858
Provider Name (Legal Business Name): NICOLE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 N FERNCREEK AVE STE A
ORLANDO FL
32803-5432
US

IV. Provider business mailing address

12380 SHADY SPRING WAY
ORLANDO FL
32828-9174
US

V. Phone/Fax

Practice location:
  • Phone: 407-898-7798
  • Fax:
Mailing address:
  • Phone: 941-374-1240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: