Healthcare Provider Details

I. General information

NPI: 1922408350
Provider Name (Legal Business Name): AMY WILDASIN APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DRIVE PHYSICIANS OFFICE CENTER, 4TH FLOOR
MORGANTOWN WV
26506
US

IV. Provider business mailing address

1 MEDICAL CENTER DRIVE PO BOX 9238
MORGANTOWN WV
26506
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4890
  • Fax:
Mailing address:
  • Phone: 304-293-2706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN71210-FNP-BC
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: