Provider Demographics
NPI:1023519337
Name:WILSON, CHRISTINA GRACE (AGNP)
Entity type:Individual
Prefix:MS
First Name:CHRISTINA
Middle Name:GRACE
Last Name:WILSON
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 LUDLOW ST APT 1D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-3253
Mailing Address - Country:US
Mailing Address - Phone:914-844-5229
Mailing Address - Fax:
Practice Address - Street 1:240 E 38TH ST FL 19
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2708
Practice Address - Country:US
Practice Address - Phone:646-501-4834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308575363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health