Provider Demographics
NPI:1316791528
Name:AMANDA WIKAN LLC
Entity type:Organization
Organization Name:AMANDA WIKAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIKAN
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:563-277-2015
Mailing Address - Street 1:511 ROSE GARDEN CV
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-2354
Mailing Address - Country:US
Mailing Address - Phone:563-277-2015
Mailing Address - Fax:
Practice Address - Street 1:250 S MCCORMICK ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4714
Practice Address - Country:US
Practice Address - Phone:563-277-2015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty