Healthcare Provider Details

I. General information

NPI: 1801456074
Provider Name (Legal Business Name): AMANDA R WITLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 25TH ST S
FARGO ND
58103-2367
US

IV. Provider business mailing address

1037 1ST ST N
FARGO ND
58102-3727
US

V. Phone/Fax

Practice location:
  • Phone: 701-241-1360
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR43988
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: