Healthcare Provider Details

I. General information

NPI: 1043701741
Provider Name (Legal Business Name): LAUREN LEA WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN LEA BRYANT MD

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 M D LN STE B
TALLAHASSEE FL
32308-5349
US

IV. Provider business mailing address

2606 CENTENNIAL PL
TALLAHASSEE FL
32308-0572
US

V. Phone/Fax

Practice location:
  • Phone: 850-641-7961
  • Fax: 850-312-3983
Mailing address:
  • Phone: 850-205-0189
  • Fax: 850-329-2903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME174839
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101280261
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: