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: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 PARK AVE STE 1
PORTLAND ME
04102-2927
US

IV. Provider business mailing address

180 PARK AVE
PORTLAND ME
04102-2957
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-2141
  • Fax: 207-874-2164
Mailing address:
  • Phone: 207-874-2141
  • Fax: 207-874-2164

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: