Healthcare Provider Details

I. General information

NPI: 1134871775
Provider Name (Legal Business Name): AMANDA WILLIS RN IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMANDA WILSON RN IBCLC

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 LAKEVILLE DR STE 304
KINGWOOD TX
77339-2694
US

IV. Provider business mailing address

1621 LAKEVILLE DR STE 304
KINGWOOD TX
77339-2694
US

V. Phone/Fax

Practice location:
  • Phone: 281-305-0411
  • Fax: 281-572-0627
Mailing address:
  • Phone: 281-305-0411
  • Fax: 281-572-0627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-305357
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number780850
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: