MEDICARE: MRS. POLLYANNA WILSON FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	335079	NY

General Provider Information

NPI Number	:	1487884276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. POLLYANNA WILSON FNP

Provider Business Mailing Address
First Line	:	PO BOX 746087
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6087
Country	:	US
Telephone Number	:	312-733-9730
Fax Number	:

Provider Business Practice Location Address
First Line	:	1048 BEACH 20TH ST
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-3900
Country	:	US
Telephone Number	:	718-765-6342
Fax Number	:	929-374-1132

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2009
Last Update Date	:	11/13/2024

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