Provider Demographics
NPI:1366979643
Name:WILSON, LUEQUAYN TAE (NURSE)
Entity type:Individual
Prefix:
First Name:LUEQUAYN
Middle Name:TAE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 ALOMA AVE # 219
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3752
Mailing Address - Country:US
Mailing Address - Phone:407-497-7409
Mailing Address - Fax:
Practice Address - Street 1:3001 ALOMA AVE # 219
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3752
Practice Address - Country:US
Practice Address - Phone:407-497-7409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2017051710580007Medicaid