Healthcare Provider Details

I. General information

NPI: 1598573776
Provider Name (Legal Business Name): SHANICE WILSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4979 HARLEM RD
AMHERST NY
14226-2547
US

IV. Provider business mailing address

5792 MAIN ST
WILLIAMSVILLE NY
14221-5702
US

V. Phone/Fax

Practice location:
  • Phone: 716-923-4381
  • Fax: 716-923-4384
Mailing address:
  • Phone: 716-923-4380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number713224
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number312163
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: