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General NPI Number Information
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NPI Number | 1407850365
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Entity Type | Individual
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Provider Name | CARLENE A. WILSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 06/09/2005
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Last Update Date | 06/09/2014
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Provider Practice Location Address
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Address Line | 6038 W NORDLING LOOP
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City | CRYSTAL RIVER
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State | FL
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Zip | 34429
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Country | US
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Telephone | 352-563-5070
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Fax | 352-795-4322
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Provider Business Mailing Address
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Address Line | 6038 W NORDLING LOOP
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City | CRYSTAL RIVER
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State | FL
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Zip | 34429
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Country | US
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Telephone | 352-563-5070
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Fax | 352-795-4322
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME93743
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME93743
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License Number State | FL
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