Provider Demographics
NPI:1437711991
Name:WILTSHIRE, AMANDA L (AGNP-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:L
Last Name:WILTSHIRE
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 COUNTY ROAD 316
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:MS
Mailing Address - Zip Code:38917-6536
Mailing Address - Country:US
Mailing Address - Phone:662-417-3623
Mailing Address - Fax:
Practice Address - Street 1:1300 SUNSET DR STE A
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4081
Practice Address - Country:US
Practice Address - Phone:662-226-1646
Practice Address - Fax:662-227-1599
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903415207R00000X, 363LA2200X, 363LG0600X, 363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care