Provider Demographics
NPI:1700534534
Name:WILSON, ANTOINETTE NICHOL
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:NICHOL
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 1:13575 58TH ST N STE 200
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-3739
Mailing Address - Country:US
Mailing Address - Phone:727-967-4658
Mailing Address - Fax:
Practice Address - Street 1:13575 58TH ST N STE 200
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3739
Practice Address - Country:US
Practice Address - Phone:727-396-1285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)