| NPI | 1114597168 |
|---|---|
| Former Name | AMANDA JO CARLSON |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 11274-033) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WI 2019053373) |
| Enumeration Date | 2021-06-30 |
| Last Update Date | 2024-03-04 |