Provider Demographics
NPI:1609271899
Name:WILKES, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:WILKES
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 1:664 ORANGE CT
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2413
Mailing Address - Country:US
Mailing Address - Phone:321-208-0245
Mailing Address - Fax:321-506-0926
Practice Address - Street 1:664 ORANGE COURT
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-208-0245
Practice Address - Fax:321-406-0926
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906685172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6906685Medicaid
FL6906685OtherADULT FAMILY CARE HOME