Provider Demographics
NPI:1346137007
Name:WILSON, AMANDA (RN, AGACNP STUDENT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, AGACNP STUDENT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:MULLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:740 PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-6657
Mailing Address - Country:US
Mailing Address - Phone:240-577-3323
Mailing Address - Fax:
Practice Address - Street 1:740 PINEWOOD DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-6657
Practice Address - Country:US
Practice Address - Phone:240-577-3323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program