Provider Demographics
NPI:1265862825
Name:WILSON, CYNTHIA
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:WILSON
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 1:404 IXORIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-6250
Mailing Address - Country:US
Mailing Address - Phone:772-468-3910
Mailing Address - Fax:772-468-3979
Practice Address - Street 1:404 IXORIA AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-6250
Practice Address - Country:US
Practice Address - Phone:772-468-3910
Practice Address - Fax:772-468-3979
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1154439958Medicaid