Healthcare Provider Details

I. General information

NPI: 1568310274
Provider Name (Legal Business Name): AMBER WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2026
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 US ROUTE 66 W STE C
MORIARTY NM
87035-1039
US

IV. Provider business mailing address

15 WOODPECKER LN
MORIARTY NM
87035-5392
US

V. Phone/Fax

Practice location:
  • Phone: 505-226-1566
  • Fax: 505-521-5191
Mailing address:
  • Phone: 505-226-1460
  • Fax: 505-521-5191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: