Provider Demographics
NPI:1851803654
Name:WILSON, AMANDA M (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1645
Mailing Address - Country:US
Mailing Address - Phone:218-546-7000
Mailing Address - Fax:218-546-4646
Practice Address - Street 1:320 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1645
Practice Address - Country:US
Practice Address - Phone:218-546-7000
Practice Address - Fax:218-546-4646
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3785133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered