Provider Demographics
NPI:1952711038
Name:WILEY, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15600 S. U.S. HWY 441
Mailing Address - Street 2:B
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491
Mailing Address - Country:US
Mailing Address - Phone:352-307-0073
Mailing Address - Fax:352-307-2073
Practice Address - Street 1:15600 S. U.S. HWY 441
Practice Address - Street 2:B
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491
Practice Address - Country:US
Practice Address - Phone:352-307-0073
Practice Address - Fax:352-307-2073
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 4913225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT4913OtherOT LICENSE NUMBER