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General NPI Number Information
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NPI Number | 1619647070
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Entity Type | Individual
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Provider Name | GLORIA WILSON
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Gender | Female
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Dates
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Enumeration Date | 09/16/2021
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Last Update Date | 09/16/2021
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Provider Practice Location Address
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Address Line | 6943 LUCKY DR E
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City | JACKSONVILLE
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State | FL
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Zip | 32208-4187
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Country | US
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Telephone | 904-428-2930
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Fax | 904-586-2044
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Provider Business Mailing Address
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Address Line | 6943 LUCKY DR E
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City | JACKSONVILLE
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State | FL
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Zip | 32208-4187
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Country | US
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Telephone | 904-428-2930
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Fax | 904-586-2044
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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 | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | NA
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License Number State | FL
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