Organization
DISTINCTIVE DERMATOLOGY PLLC
Active
Other names
Lake Wales Dermatology
Organization subpart
No
Provider details
NPI number
Authorized official
RAYMOND KNISLEY (OWNER)
(863) 269-0790
Entity
Organization
Contact information
Practice address
134 E TILLMAN AVE, LAKE WALES, FL 33853-4130
(863) 269-0790
Mailing address
134 E TILLMAN AVE, LAKE WALES, FL 33853-4130
(863) 269-0790
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
—
Other
Enumeration date
03/19/2021
Last updated
04/14/2021
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