Provider Demographics
NPI:1467825950
Name:WILSON, AMANDA S
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12108 AUBURN CT
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-8466
Mailing Address - Country:US
Mailing Address - Phone:614-506-9720
Mailing Address - Fax:
Practice Address - Street 1:12108 AUBURN CT
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-8466
Practice Address - Country:US
Practice Address - Phone:614-506-9720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2022-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH159264164W00000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No164W00000XNursing Service ProvidersLicensed Practical Nurse