Provider Demographics
NPI:1437963113
Name:WILSON, AMY M
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 2ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-5583
Mailing Address - Country:US
Mailing Address - Phone:760-464-9781
Mailing Address - Fax:
Practice Address - Street 1:29805 PACIFIC HWY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4233
Practice Address - Country:US
Practice Address - Phone:760-464-9781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA720032163WE0003X
WA61282453163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WE0003XNursing Service ProvidersRegistered NurseEmergency