Provider Demographics
NPI:1255023677
Name:NELSON, AMANDA (HIS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MARITIME DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-2922
Mailing Address - Country:US
Mailing Address - Phone:920-860-8172
Mailing Address - Fax:920-682-3811
Practice Address - Street 1:1000 MARITIME DR STE 101
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-2922
Practice Address - Country:US
Practice Address - Phone:920-860-8172
Practice Address - Fax:920-682-3811
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2050-60237700000X
IL3487237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist