Individual
DELANIA TYEVETTE WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
2270 PINE AVE, MOUNT DORA, FL 32757-6407
(352) 396-7727
Mailing address
2270 PINE AVE, MOUNT DORA, FL 32757-6407
(352) 396-7727
Taxonomy
Speciality
Code
Description
License number
State
261QD1600X
Developmental Disabilities Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
104575900
—
FL
Enumeration date
02/14/2022
Last updated
02/14/2022
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