Provider Demographics
NPI:1629523519
Name:WILSON, EMILY BERNICE (RN, CPNP-PC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:BERNICE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E 59TH ST APT 4B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2387
Mailing Address - Country:US
Mailing Address - Phone:614-499-7616
Mailing Address - Fax:
Practice Address - Street 1:4701 QUEENS BLVD STE 303
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104
Practice Address - Country:US
Practice Address - Phone:718-707-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-20
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22717811163W00000X
NY382817363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse