Provider Demographics
NPI:1023573755
Name:WILSON, ELIZABETH (DOM, RD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DOM, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SW MADISON CIR N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-1314
Mailing Address - Country:US
Mailing Address - Phone:256-682-1763
Mailing Address - Fax:
Practice Address - Street 1:8424 4TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-3659
Practice Address - Country:US
Practice Address - Phone:256-682-1763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
FL4024171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered