Provider Demographics
NPI:1710397260
Name:WILSON, AMY KELM (ANP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KELM
Last Name:WILSON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:K
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ANP
Mailing Address - Street 1:5205 WELCHSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-5905
Mailing Address - Country:US
Mailing Address - Phone:901-355-2879
Mailing Address - Fax:
Practice Address - Street 1:877 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2807
Practice Address - Country:US
Practice Address - Phone:901-545-8785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN18713363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily