Healthcare Provider Details

I. General information

NPI: 1982197026
Provider Name (Legal Business Name): NICOLE CLAIRE WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 E ROLLINS ST STE 11100
ORLANDO FL
32804-5570
US

IV. Provider business mailing address

833 CHESTNUT ST STE 520
PHILADELPHIA PA
19107-4430
US

V. Phone/Fax

Practice location:
  • Phone: 844-407-4070
  • Fax:
Mailing address:
  • Phone: 267-339-7843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number301996
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME141949
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME141949
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: