Provider Demographics
NPI:1942182472
Name:WILSON, LISA NICOLE (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:NICOLE
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 1:195 N UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2143
Mailing Address - Country:US
Mailing Address - Phone:347-423-1784
Mailing Address - Fax:
Practice Address - Street 1:640 BELLE TERRE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1936
Practice Address - Country:US
Practice Address - Phone:631-828-5361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF312374-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner