MEDICARE: IYANA WILMOTT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	879473	NY

General Provider Information

NPI Number	:	1235685306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IYANA WILMOTT

Provider Business Mailing Address
First Line	:	15614 78TH ST
Second Line	:
City	:	HOWARD BEACH
State	:	NY
Zip	:	11414-2514
Country	:	US
Telephone Number	:	516-567-7114
Fax Number	:

Provider Business Practice Location Address
First Line	:	15614 78TH ST
Second Line	:
City	:	HOWARD BEACH
State	:	NY
Zip	:	11414-2514
Country	:	US
Telephone Number	:	516-567-7114
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2016
Last Update Date	:	08/29/2016

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Directions to “ IYANA WILMOTT ” Practice Location

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