Provider Demographics
NPI:1619531951
Name:WILT, MOLLIE MARIE (PA)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:MARIE
Last Name:WILT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:MARIE
Other - Last Name:PLEASANTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:900 VILLAGE SQUARE XING STE 290
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4552
Mailing Address - Country:US
Mailing Address - Phone:239-360-3792
Mailing Address - Fax:239-666-9211
Practice Address - Street 1:2910 SE 3RD CT STE A
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-0484
Practice Address - Country:US
Practice Address - Phone:352-732-0339
Practice Address - Fax:352-732-3715
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant