Healthcare Provider Details

I. General information

NPI: 1689345902
Provider Name (Legal Business Name): AMY WILSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 W COLE RD
BIDDEFORD ME
04005-9430
US

IV. Provider business mailing address

22 W COLE RD STE 101
BIDDEFORD ME
04005-9431
US

V. Phone/Fax

Practice location:
  • Phone: 207-780-6565
  • Fax:
Mailing address:
  • Phone: 207-780-6565
  • Fax: 208-878-6565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP211446
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: