Provider Demographics
NPI:1629509922
Name:WILSON, AMY LYNN (DO)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:720 BROOKER CREEK BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-2937
Mailing Address - Country:US
Mailing Address - Phone:813-854-2003
Mailing Address - Fax:813-346-5378
Practice Address - Street 1:6671 13TH AVE N STE D
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5417
Practice Address - Country:US
Practice Address - Phone:727-381-1147
Practice Address - Fax:727-345-2489
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS16781208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics