Healthcare Provider Details

I. General information

NPI: 1356032056
Provider Name (Legal Business Name): WILDWINE BELIZAIRE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7560 BUTNER RD
FAIRBURN GA
30213-1914
US

IV. Provider business mailing address

3800 S OCEAN DR STE 209
HOLLYWOOD FL
33019-2915
US

V. Phone/Fax

Practice location:
  • Phone: 800-266-8874
  • Fax: 877-366-4776
Mailing address:
  • Phone: 800-226-8874
  • Fax: 877-366-4776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN315873
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: