Provider Demographics
NPI:1619647070
Name:WILSON, GLORIA
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
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 1:6943 LUCKY DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-4187
Mailing Address - Country:US
Mailing Address - Phone:904-428-2930
Mailing Address - Fax:904-586-2044
Practice Address - Street 1:6943 LUCKY DR E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-4187
Practice Address - Country:US
Practice Address - Phone:904-428-2930
Practice Address - Fax:904-586-2044
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLNA208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNAOtherNA