Healthcare Provider Details

I. General information

NPI: 1144948779
Provider Name (Legal Business Name): AMANDA WIPERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 08/19/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17273 STATE ROUTE 104
CHILLICOTHEE OH
45601-9718
US

IV. Provider business mailing address

14734 S PERRY RD
LAURELVILLE OH
43135-9708
US

V. Phone/Fax

Practice location:
  • Phone: 740-773-1141
  • Fax:
Mailing address:
  • Phone: 740-577-6619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN321584
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: