Provider Demographics
NPI:1538652581
Name:WILEY, AMY HELEN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:HELEN
Last Name:WILEY
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 1:1210 2ND ST N APT A
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-7281
Mailing Address - Country:US
Mailing Address - Phone:740-502-7183
Mailing Address - Fax:
Practice Address - Street 1:1210 2ND ST N APT A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-7281
Practice Address - Country:US
Practice Address - Phone:740-502-7183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111747363A00000X
IL085006890363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant