Provider Demographics
NPI:1558989046
Name:WILSON, AMIE MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:MICHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:AMIE
Other - Middle Name:MICHELLE
Other - Last Name:FYKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:16065 LAMONTE DR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-1405
Mailing Address - Country:US
Mailing Address - Phone:318-239-7045
Mailing Address - Fax:
Practice Address - Street 1:16065 LAMONTE DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1405
Practice Address - Country:US
Practice Address - Phone:318-239-7045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA214398363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily