Provider Demographics
NPI:1598573776
Name:WILSON, SHANICE (NP)
Entity type:Individual
Prefix:
First Name:SHANICE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5792 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5702
Mailing Address - Country:US
Mailing Address - Phone:716-923-4380
Mailing Address - Fax:
Practice Address - Street 1:4979 HARLEM RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-2547
Practice Address - Country:US
Practice Address - Phone:716-923-4381
Practice Address - Fax:716-923-4384
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY713224363L00000X
NY312163363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner