Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 9228639 | FL |
NPI | 1023593373 |
---|---|
Provider Name | Bridgette Wilson |
First Address | Maitland, FL 32751-4485 |
Second Address | Maitland, FL 32751-4485 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2018 |
Last Update Date | 02/10/2018 |