Individual
LISA NICOLE WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
640 BELLE TERRE RD, PORT JEFFERSON, NY 11777-1936
(631) 828-5361
Mailing address
195 N UTICA AVE, NORTH MASSAPEQUA, NY 11758-2143
(347) 423-1784
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
F312374-01
NY
Other
Enumeration date
07/24/2025
Last updated
07/24/2025
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