Provider Demographics
NPI:1417558370
Name:WILKE, MARISOL
Entity Type:Individual
Prefix:MRS
First Name:MARISOL
Middle Name:
Last Name:WILKE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARISOL
Other - Middle Name:
Other - Last Name:WILKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-312-3459
Mailing Address - Fax:321-768-5090
Practice Address - Street 1:1223 GATEWAY DR STE 1A
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-312-3459
Practice Address - Fax:321-409-1792
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9369651363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNV417OtherFL MEDICARE