Provider Demographics
NPI:1760868723
Name:WILSON, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:34 W. 5TH ST.
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:43008
Mailing Address - Country:US
Mailing Address - Phone:740-281-9617
Mailing Address - Fax:
Practice Address - Street 1:34 W 5TH ST
Practice Address - Street 2:
Practice Address - City:BUCKEYE LAKE
Practice Address - State:OH
Practice Address - Zip Code:43008
Practice Address - Country:US
Practice Address - Phone:740-281-9617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide