Individual
MS. WANDA FAYE WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
2510 ST AUGUSTINE RD, MONTICELLO, FL 32344-6938
(850) 780-0426
Mailing address
2510 ST AUGUSTINE RD, MONTICELLO, FL 32344-6938
(850) 780-0426
Taxonomy
Speciality
Code
Description
License number
State
311ZA0620X
Adult Care Home Facility
Primary
6906542
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004873400
—
FL
Enumeration date
08/13/2013
Last updated
08/13/2013
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