Provider Demographics
NPI:1932668456
Name:WILSON, AMY ANNETTE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ANNETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 WILLOW PINE CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-6806
Mailing Address - Country:US
Mailing Address - Phone:804-551-6811
Mailing Address - Fax:
Practice Address - Street 1:TAPPAHANNOCK PRIMARY CARE
Practice Address - Street 2:1362 TAPPAHANNOCK BLVD
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560
Practice Address - Country:US
Practice Address - Phone:804-443-5378
Practice Address - Fax:804-443-9667
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176805363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner