Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LF0000X | Nurse Practitioner - Family Medicine | A810519 | MS |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | APN0000017457 | TN |
NPI | 1003256496 |
---|---|
Provider Name | Amanda Wilson |
First Address | Germantown, TN 38183-1071 |
Second Address | Collierville, TN 38017-2538 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2013 |
Last Update Date | 08/08/2014 |