Healthcare Provider Details

I. General information

NPI: 1043051618
Provider Name (Legal Business Name): REGINA WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 FOREST HILL BLVD
WELLINGTON FL
33414-6103
US

IV. Provider business mailing address

9576 MARSH WREN CT APT 104
LAKE WORTH FL
33467-5273
US

V. Phone/Fax

Practice location:
  • Phone: 561-798-8500
  • Fax:
Mailing address:
  • Phone: 914-382-8126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: