Provider Demographics
NPI:1508156506
Name:WILFORD, AMANDA DAWN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DAWN
Last Name:WILFORD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:ALBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1416 CROWN DRIVE
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2548
Mailing Address - Country:US
Mailing Address - Phone:660-627-5757
Mailing Address - Fax:660-627-5802
Practice Address - Street 1:52334 BUSINESS HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MO
Practice Address - Zip Code:63556-3040
Practice Address - Country:US
Practice Address - Phone:660-265-1042
Practice Address - Fax:660-265-1043
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000163306363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO261866Medicare Oscar/Certification
MO141570004Medicare PIN