Healthcare Provider Details

I. General information

NPI: 1114832789
Provider Name (Legal Business Name): AMANDA WILSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CHUGACH AVE
KENAI AK
99611-7028
US

IV. Provider business mailing address

817 52ND ST S
GREAT FALLS MT
59405-5746
US

V. Phone/Fax

Practice location:
  • Phone: 907-260-7200
  • Fax:
Mailing address:
  • Phone: 406-498-9876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number254264
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: