Healthcare Provider Details

I. General information

NPI: 1629982608
Provider Name (Legal Business Name): AMANDA ROSE WILSON APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 NE 10TH AVE
PAYETTE ID
83661-5420
US

IV. Provider business mailing address

8495 W GALACTIC CT
BOISE ID
83709-7881
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-9376
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9481637
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: