Provider Demographics
NPI:1952942401
Name:WILSON, TANEKA D
Entity Type:Individual
Prefix:
First Name:TANEKA
Middle Name:D
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 1:3209 SW 34TH AVENUE CIR
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-3372
Mailing Address - Country:US
Mailing Address - Phone:352-789-6795
Mailing Address - Fax:352-789-6796
Practice Address - Street 1:3209 SW 34TH AVENUE CIR
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-3372
Practice Address - Country:US
Practice Address - Phone:352-789-6795
Practice Address - Fax:352-789-6796
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL690063196251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL690063196Medicaid