Provider Demographics
NPI:1306536552
Name:ISIDORE, WIDELINE
Entity type:Individual
Prefix:
First Name:WIDELINE
Middle Name:
Last Name:ISIDORE
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 1:8761 S CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-2525
Mailing Address - Country:US
Mailing Address - Phone:305-494-9899
Mailing Address - Fax:
Practice Address - Street 1:8761 S CRESCENT DR
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-2525
Practice Address - Country:US
Practice Address - Phone:305-494-9899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11025877363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health