Healthcare Provider Details

I. General information

NPI: 1104508027
Provider Name (Legal Business Name): AMY ELIZABETH WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 FORT WASHINGTON AVE
NEW YORK NY
10032-3729
US

IV. Provider business mailing address

3119 33RD ST APT 11
ASTORIA NY
11106-2013
US

V. Phone/Fax

Practice location:
  • Phone: 212-342-6917
  • Fax:
Mailing address:
  • Phone: 973-809-9985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF352460-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: