Provider Demographics
NPI:1477030161
Name:WILSON, AMY LOUISE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LOUISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2893 VETERANS MEMORIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-3526
Mailing Address - Country:US
Mailing Address - Phone:636-724-1100
Mailing Address - Fax:
Practice Address - Street 1:2893 VETERANS MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-3526
Practice Address - Country:US
Practice Address - Phone:636-724-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018002346363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily