Healthcare Provider Details

I. General information

NPI: 1972491199
Provider Name (Legal Business Name): AMANDA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2025
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4597
US

IV. Provider business mailing address

2557 FOX RUN RD SW APT 1
WYOMING MI
49519-4121
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-2700
  • Fax:
Mailing address:
  • Phone: 616-690-7379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: