Healthcare Provider Details

I. General information

NPI: 1942182472
Provider Name (Legal Business Name): LISA NICOLE WILSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2025
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 BELLE TERRE RD
PORT JEFFERSON NY
11777-1936
US

IV. Provider business mailing address

195 N UTICA AVE
NORTH MASSAPEQUA NY
11758-2143
US

V. Phone/Fax

Practice location:
  • Phone: 631-828-5361
  • Fax:
Mailing address:
  • Phone: 347-423-1784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF312374-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: