Provider Demographics
NPI:1265637987
Name:WICKER, AMANDA L (LPN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:WICKER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:EAST PRAIRIE
Mailing Address - State:MO
Mailing Address - Zip Code:63845-1526
Mailing Address - Country:US
Mailing Address - Phone:573-649-9411
Mailing Address - Fax:573-649-9442
Practice Address - Street 1:106 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63845-1526
Practice Address - Country:US
Practice Address - Phone:573-649-9411
Practice Address - Fax:573-649-9442
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003028629164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse