MEDICARE: MISS ADRIENNE A WILSON I

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	224Z00000X	Occupational Therapy Assistant	OTA16298	FL

General Provider Information

NPI Number	:	1821595851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ADRIENNE A WILSON I

Provider Business Mailing Address
First Line	:	3756 CORAL TREE CIR
Second Line	:
City	:	COCONUT CREEK
State	:	FL
Zip	:	33073-4424
Country	:	US
Telephone Number	:	954-856-8450
Fax Number	:

Provider Business Practice Location Address
First Line	:	1750 N UNIVERSITY DR # 105-109
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33071-8903
Country	:	US
Telephone Number	:	954-356-2878
Fax Number	:

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

Provider Enumeration Date	:	04/06/2018
Last Update Date	:	04/06/2018

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