Distinctive Dermatology PLLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

DISTINCTIVE DERMATOLOGY PLLC

Doing business as

Lake Wales Dermatology

Practice address

134 E Tillman Ave
Lake Wales, FL 33853-4130

Phone

(863) 269-0790

NPI assigned

Mar 19, 2021

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Raymond Knisley

Title

Owner

Phone

(863) 269-0790

Specialties & licenses 1

Addresses

Other names 1

• Lake Wales Dermatology Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1616112000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1618358400000",
    "number": "1962088138",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "134 E TILLMAN AVE",
            "city": "LAKE WALES",
            "state": "FL",
            "postal_code": "338534130",
            "telephone_number": "863-269-0790"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "134 E TILLMAN AVE",
            "city": "LAKE WALES",
            "state": "FL",
            "postal_code": "338534130",
            "telephone_number": "863-269-0790"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1255 State Road 60 E Ste 100",
            "address_purpose": "LOCATION",
            "city": "Lake Wales",
            "state": "FL",
            "postal_code": "338534310",
            "country_code": "US",
            "telephone_number": "863-269-0790",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "DISTINCTIVE DERMATOLOGY PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-03-19",
        "last_updated": "2021-04-14",
        "certification_date": "2021-04-14",
        "status": "A",
        "authorized_official_last_name": "KNISLEY",
        "authorized_official_first_name": "RAYMOND",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "863-269-0790"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Wales Dermatology",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Nydia Gricelle Deltoro Rivera, MD, WCC. DWC, CWS
• Theresa Sunshine Delvalle, COTA
• Veronica E Diaz
• Marianne Dimetry, PHARMD
• Sentreila Collen Dinkens, RN
• Silas Doku
• Sandra Collins Domanski, PT
• Aaron Rene Allick Douen, M.D.
• Dr Behal'S Family Practice Clinic
• Dream Achievers Resource and Development Center Inc

• Dermatology Physician in Lake Wales, FL
• Providers in Lake Wales, FL by specialty
• Dermatology Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 14, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.