Provider Demographics
NPI:1609314061
Name:WILSON, CANDICE MELODY (ARNP)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:MELODY
Last Name:WILSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 RILEY RD
Mailing Address - Street 2:
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-5419
Mailing Address - Country:US
Mailing Address - Phone:407-930-6900
Mailing Address - Fax:321-203-4669
Practice Address - Street 1:63 RILEY RD
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-5419
Practice Address - Country:US
Practice Address - Phone:407-930-6900
Practice Address - Fax:321-203-4669
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-06
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9327498363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24929100Medicaid