Healthcare Provider Details

I. General information

NPI: 1457613861
Provider Name (Legal Business Name): SOPHIA LORRAINE WILSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SOPHIA LORRAINE WILSON FNP

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 CLEVELAND CLINIC BLVD
WESTON FL
33331-3609
US

IV. Provider business mailing address

2950 CLEVELAND CLINIC BLVD
WESTON FL
33331-3609
US

V. Phone/Fax

Practice location:
  • Phone: 954-659-5000
  • Fax: 954-659-6789
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number337155
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9334166
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: