Provider Demographics
NPI:1356096770
Name:WILSON, DELANIA TYEVETTE
Entity Type:Individual
Prefix:
First Name:DELANIA
Middle Name:TYEVETTE
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 1:2270 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6407
Mailing Address - Country:US
Mailing Address - Phone:352-396-7727
Mailing Address - Fax:
Practice Address - Street 1:2270 PINE AVE
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6407
Practice Address - Country:US
Practice Address - Phone:352-396-7727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104575900Medicaid