Provider Demographics
NPI:1861002883
Name:WILSON, AMANDA L (PEDIATRIC NP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:PEDIATRIC NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17444 Q DR N
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-9418
Mailing Address - Country:US
Mailing Address - Phone:517-243-7774
Mailing Address - Fax:
Practice Address - Street 1:358 E CHICAGO ST STE 202
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2073
Practice Address - Country:US
Practice Address - Phone:517-279-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704264564363LP0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse