Provider Demographics
NPI:1992297634
Name:THEODORE, AWILDA
Entity type:Individual
Prefix:MS
First Name:AWILDA
Middle Name:
Last Name:THEODORE
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 1:1601 BELVEDERE RD STE 300E
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-1554
Mailing Address - Country:US
Mailing Address - Phone:561-507-1601
Mailing Address - Fax:561-214-6139
Practice Address - Street 1:1601 BELVEDERE RD STE 300E
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-1554
Practice Address - Country:US
Practice Address - Phone:561-507-1601
Practice Address - Fax:561-214-6139
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251F00000X
FL30212801251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30212801OtherNURSE REGISTRY LICENSED
FLL24000107190OtherLLC