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General NPI Number Information
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NPI Number | 1598448938
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Entity Type | Individual
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Provider Name | MARILYN MARIE WILSON
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Gender | Female
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Dates
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Enumeration Date | 08/11/2023
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Last Update Date | 08/11/2023
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Provider Practice Location Address
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Address Line | 14500 US HIGHWAY 301 S
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City | STARKE
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State | FL
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Zip | 32091-7858
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Country | US
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Telephone | 904-964-2250
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Fax | 904-964-2425
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Provider Business Mailing Address
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Address Line | 5901 THOMAS LN
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City | HAMPTON
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State | FL
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Zip | 32044-4466
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Country | US
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Telephone | 904-964-2250
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Fax | 904-964-2425
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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 | 156FX1800X
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Taxonomy Name | Optician
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License Number | DO4862
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License Number State | FL
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