Provider Demographics
NPI:1598448938
Name:WILSON, MARILYN MARIE
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:MARIE
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 1:5901 THOMAS LN
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:FL
Mailing Address - Zip Code:32044-4466
Mailing Address - Country:US
Mailing Address - Phone:904-964-2250
Mailing Address - Fax:904-964-2425
Practice Address - Street 1:14500 US HIGHWAY 301 S
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-7858
Practice Address - Country:US
Practice Address - Phone:904-964-2250
Practice Address - Fax:904-964-2425
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO4862156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician