Healthcare Provider Details

I. General information

NPI: 1144568767
Provider Name (Legal Business Name): AMANDA S WILES NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 5TH AVE NE
JAMESTOWN ND
58401-3437
US

IV. Provider business mailing address

PO BOX 2168
FARGO ND
58107-2168
US

V. Phone/Fax

Practice location:
  • Phone: 701-253-4000
  • Fax:
Mailing address:
  • Phone: 701-234-2119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2013001306
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR39620
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License NumberR39620
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: