Provider Demographics
NPI:1437468097
Name:WILSON, CHRISTINE DEBRA (APRN)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:DEBRA
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Mailing Address - Fax:
Practice Address - Street 1:699 W COCOA BEACH CSWY STE 601
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3562
Practice Address - Country:US
Practice Address - Phone:321-868-5833
Practice Address - Fax:321-868-5854
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9249801363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDX159XOtherMEDICARE
FL014571800Medicaid
FLDX159ZMedicare PIN