Provider Demographics
NPI:1790348175
Name:WILKINS, JULIANNE GRACE
Entity Type:Individual
Prefix:
First Name:JULIANNE
Middle Name:GRACE
Last Name:WILKINS
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 1:1110 NIKKI VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4868
Mailing Address - Country:US
Mailing Address - Phone:813-444-5567
Mailing Address - Fax:813-444-5569
Practice Address - Street 1:1110 NIKKI VIEW DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4868
Practice Address - Country:US
Practice Address - Phone:813-444-5567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-21
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113388363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9226OtherDIETITIAN NUTRITIONIST LICENSURE
86014726OtherCOMMISSION ON DIETETIC REGISTRATION