=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124789615
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALTHEA CAROLINE WILMOT APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2022
-----------------------------------------------------
Last Update Date | 01/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2401 QUANTUM BLVD
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33426-8612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-707-1333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10688 OLD HAMMOCK WAY
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-3148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-707-0133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11017137
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------