Provider Demographics
NPI:1861860611
Name:WILSON, AKISHA (NP)
Entity Type:Individual
Prefix:
First Name:AKISHA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AKISHA
Other - Middle Name:
Other - Last Name:WILSON-PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:160 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4658
Mailing Address - Country:US
Mailing Address - Phone:631-273-7105
Mailing Address - Fax:631-273-7253
Practice Address - Street 1:160 4TH ST
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4658
Practice Address - Country:US
Practice Address - Phone:631-273-7105
Practice Address - Fax:631-273-7253
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339950363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily