Provider Demographics
NPI:1063185072
Name:JEVAHIRIAN, AMANDA (NP)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:JEVAHIRIAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4700 SCHAEFER RD STE 340
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3743
Mailing Address - Country:US
Mailing Address - Phone:313-561-5100
Mailing Address - Fax:313-565-0309
Practice Address - Street 1:25650 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2096
Practice Address - Country:US
Practice Address - Phone:313-383-1897
Practice Address - Fax:313-383-6018
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704300662NSA210LV363LF0000X
MI4704300662363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily