Provider Demographics
NPI:1770109886
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 1:1812 FEATHERSTONE RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3413
Mailing Address - Country:US
Mailing Address - Phone:703-643-4066
Mailing Address - Fax:571-316-1654
Practice Address - Street 1:1812 FEATHERSTONE RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3413
Practice Address - Country:US
Practice Address - Phone:703-643-4066
Practice Address - Fax:571-316-1654
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health