Provider Demographics
NPI:1104883156
Name:WILSON, MARCELLA CHRISTINE (DOM, AP)
Entity type:Individual
Prefix:MS
First Name:MARCELLA
Middle Name:CHRISTINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DOM, AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 NW 14TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-2506
Mailing Address - Country:US
Mailing Address - Phone:352-284-5937
Mailing Address - Fax:
Practice Address - Street 1:901 NW 8TH AVE
Practice Address - Street 2:SUITE A-1
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-5000
Practice Address - Country:US
Practice Address - Phone:352-284-5937
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 2178171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC002FOtherBLUE CROSS/BLUE SHIELD