Provider Demographics
NPI:1477240133
Name:WILCOX, AMANDA JO (MPH, RDN, LD/N, CLC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:WILCOX
Suffix:
Gender:F
Credentials:MPH, RDN, LD/N, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 SW 45TH TER
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-6341
Mailing Address - Country:US
Mailing Address - Phone:402-432-6442
Mailing Address - Fax:
Practice Address - Street 1:2489 DIPLOMAT PKWY E
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-5422
Practice Address - Country:US
Practice Address - Phone:239-652-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND11458133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered