Basic Information
| Provider Information | |||||||||
| NPI: | 1669714929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKINSON | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14750 BEACH BLVD APT 56 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322502354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045367266 | ||||||||
| FaxNumber: | 8138444972 | ||||||||
| Practice Location | |||||||||
| Address1: | 1564 KINGSLEY AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042640400 | ||||||||
| FaxNumber: | 9042640401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2013 | ||||||||
| LastUpdateDate: | 02/06/2019 | ||||||||
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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 | 367500000X | 1527642 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN228493 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | APRN1527642 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 010946000 | 05 | FL | MEDICAID |