Healthcare Provider Details

I. General information

NPI: 1194394908
Provider Name (Legal Business Name): AMANDA MACKENZIE WILSON MSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA MACKENZIE MCGLONE

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 SW 5TH ST
BLUE SPRINGS MO
64014-3007
US

IV. Provider business mailing address

4801 E LINWOOD BLVD
KANSAS CITY MO
64128-2226
US

V. Phone/Fax

Practice location:
  • Phone: 816-377-8277
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number202001453
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number202001453
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: