Provider Demographics
NPI:1790654119
Name:WILLY, AMANDA MARIE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:WILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:WICHERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13 SPRING CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-7135
Mailing Address - Country:US
Mailing Address - Phone:217-414-4082
Mailing Address - Fax:
Practice Address - Street 1:1021 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3901
Practice Address - Country:US
Practice Address - Phone:360-565-9511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-03
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN.RN.61057018.MSL163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse