Provider Demographics
NPI:1750877213
Name:WILSON, BROOK EDEN (APRN-C)
Entity type:Individual
Prefix:MS
First Name:BROOK
Middle Name:EDEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN-C
Other - Prefix:MS
Other - First Name:BROOKE
Other - Middle Name:EDEN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2995 DREW ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-532-1355
Mailing Address - Fax:813-635-2613
Practice Address - Street 1:3001 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-870-4421
Practice Address - Fax:813-870-4390
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9285584363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100762700Medicaid