Healthcare Provider Details

I. General information

NPI: 1265637987
Provider Name (Legal Business Name): AMANDA L WICKER LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S WASHINGTON ST
EAST PRAIRIE MO
63845-1526
US

IV. Provider business mailing address

106 S WASHINGTON ST
EAST PRAIRIE MO
63845-1526
US

V. Phone/Fax

Practice location:
  • Phone: 573-649-9411
  • Fax: 573-649-9442
Mailing address:
  • Phone: 573-649-9411
  • Fax: 573-649-9442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2003028629
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: