Provider Demographics
NPI:1548887334
Name:WILKERSON, IRENE TUNGOL
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:TUNGOL
Last Name:WILKERSON
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 1:1014 WOODLAWN RD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2215
Mailing Address - Country:US
Mailing Address - Phone:407-715-7845
Mailing Address - Fax:800-240-2085
Practice Address - Street 1:325 NORWOOD ST
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4764
Practice Address - Country:US
Practice Address - Phone:321-459-0530
Practice Address - Fax:321-459-0530
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11011310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility