Healthcare Provider Details

I. General information

NPI: 1962246207
Provider Name (Legal Business Name): AMANDA WILSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 N BLOCK AVE
FAYETTEVILLE AR
72701-5204
US

IV. Provider business mailing address

3610 N TOWER CIR
FAYETTEVILLE AR
72704-7402
US

V. Phone/Fax

Practice location:
  • Phone: 479-200-2749
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WN1003X
TaxonomyNutrition Support Registered Nurse
License NumberR090453
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: