Provider Demographics
NPI:1861002883
Name:WILSON, AMANDA L (PEDIATRIC NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:PEDIATRIC NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1515 LAKE LANSING RD STE C2
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-3752
Mailing Address - Country:US
Mailing Address - Phone:517-482-9582
Mailing Address - Fax:517-482-4304
Practice Address - Street 1:17444 Q DR N
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-9418
Practice Address - Country:US
Practice Address - Phone:517-243-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704264564163W00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse