Healthcare Provider Details

I. General information

NPI: 1467825950
Provider Name (Legal Business Name): AMANDA S WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 10/09/2022
Certification Date: 10/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12108 AUBURN CT
PICKERINGTON OH
43147-8466
US

IV. Provider business mailing address

12108 AUBURN CT
PICKERINGTON OH
43147-8466
US

V. Phone/Fax

Practice location:
  • Phone: 614-506-9720
  • Fax:
Mailing address:
  • Phone: 614-506-9720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number159264
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: