Provider Demographics
NPI:1841380334
Name:WILSON, AMY MARIE (APN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23410
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72221-3410
Mailing Address - Country:US
Mailing Address - Phone:501-224-1690
Mailing Address - Fax:501-224-1927
Practice Address - Street 1:5 SAINT VINCENT CIR STE 300
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5417
Practice Address - Country:US
Practice Address - Phone:501-552-8800
Practice Address - Fax:501-552-5343
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA001902363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159004758Medicaid
AR5V410Medicare PIN