Provider Demographics
NPI:1033200522
Name:WILKES, CONNIE L (MED)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:WILKES
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 SANCTUARY DR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32766-6613
Mailing Address - Country:US
Mailing Address - Phone:407-366-1891
Mailing Address - Fax:
Practice Address - Street 1:USAMEDDAC WUERZBURG ATTN: CREDENTIALS OFFICE
Practice Address - Street 2:UNIT 26610
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09112
Practice Address - Country:DE
Practice Address - Phone:491520-544-6422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00003983101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health