Healthcare Provider Details

I. General information

NPI: 1437725991
Provider Name (Legal Business Name): MICHELLE N C WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 NW 3RD AVE
POMPANO BEACH FL
33060-4800
US

IV. Provider business mailing address

2011 NW 3RD AVE
POMPANO BEACH FL
33060-4800
US

V. Phone/Fax

Practice location:
  • Phone: 954-786-5901
  • Fax: 954-786-0129
Mailing address:
  • Phone: 954-786-5901
  • Fax: 954-786-0129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12650
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: