Healthcare Provider Details

I. General information

NPI: 1225410921
Provider Name (Legal Business Name): EMANI I WILMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 11/27/2023
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

IV. Provider business mailing address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

V. Phone/Fax

Practice location:
  • Phone: 845-333-3370
  • Fax: 845-333-3372
Mailing address:
  • Phone: 845-333-3370
  • Fax: 845-333-3372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number655839
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number339952
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number655839
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: