Basic Information
| Provider Information | |||||||||
| NPI: | 1003147489 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1734 E HARMONY LAKE CIR | ||||||||
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| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333247123 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3301 COLLEGE AVE | ||||||||
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| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333147721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542627124 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2010 | ||||||||
| LastUpdateDate: | 11/18/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT13641 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.