Provider Demographics
NPI:1801144092
Name:WILSON, AMANDA MARIE (RN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1040 S WINTER ST
Mailing Address - Street 2:SUITE 1022
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-3876
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1040 S WINTER ST
Practice Address - Street 2:SUITE 1022
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-3876
Practice Address - Country:US
Practice Address - Phone:517-263-8905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704280384163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse