Provider Demographics
NPI:1518446517
Name:WILKERSON, AMY BETH (FNP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:BETH
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:BETH
Other - Last Name:LIBERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:1114 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7326
Practice Address - Country:US
Practice Address - Phone:843-212-8070
Practice Address - Fax:843-212-8071
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22109363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP5419Medicaid