Healthcare Provider Details

I. General information

NPI: 1942120308
Provider Name (Legal Business Name): MIKAYLA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 W LA SALLE ST
TAMPA FL
33607-5328
US

IV. Provider business mailing address

2110 W LA SALLE ST
TAMPA FL
33607-5328
US

V. Phone/Fax

Practice location:
  • Phone: 813-525-1500
  • Fax:
Mailing address:
  • Phone: 813-563-8331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: