Provider Demographics
NPI:1437711991
Name:WILTSHIRE, AMANDA L (AGNP-C)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:L
Last Name:WILTSHIRE
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 SOUTHCREST CIR STE 212
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-6721
Mailing Address - Country:US
Mailing Address - Phone:662-245-5270
Mailing Address - Fax:662-351-9471
Practice Address - Street 1:401 SOUTHCREST CIR STE 212
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6721
Practice Address - Country:US
Practice Address - Phone:662-245-5270
Practice Address - Fax:662-351-9471
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903415207R00000X, 363LA2200X, 363LG0600X, 363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care