Provider Demographics
NPI:1962264994
Name:WILSON, AMANDA KATHRYN (RN, BSN, CNOR)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KATHRYN
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, BSN, CNOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-2702
Mailing Address - Country:US
Mailing Address - Phone:712-661-8084
Mailing Address - Fax:
Practice Address - Street 1:802 KENYON RD
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5740
Practice Address - Country:US
Practice Address - Phone:515-574-6546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA155993163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant