Provider Demographics
NPI:1285083683
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:PO BOX 5014
Mailing Address - Street 2:
Mailing Address - City:AKHIOK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-5014
Mailing Address - Country:US
Mailing Address - Phone:907-836-2230
Mailing Address - Fax:907-836-2224
Practice Address - Street 1:124 AKHIOK STREET
Practice Address - Street 2:
Practice Address - City:AKHIOK
Practice Address - State:AK
Practice Address - Zip Code:99615
Practice Address - Country:US
Practice Address - Phone:907-836-2230
Practice Address - Fax:907-836-2224
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK15-1355-II172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker