Provider Demographics
NPI:1235685306
Name:WILMOTT, IYANA
Entity Type:Individual
Prefix:
First Name:IYANA
Middle Name:
Last Name:WILMOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15614 78TH ST
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-2514
Mailing Address - Country:US
Mailing Address - Phone:516-567-7114
Mailing Address - Fax:
Practice Address - Street 1:15614 78TH ST
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-2514
Practice Address - Country:US
Practice Address - Phone:516-567-7114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY879473174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist