Provider Demographics
NPI:1063625077
Name:WHITE, AMANDA MARIE (STNA)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:WHITE
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9180 STATE ROUTE 28
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:OH
Mailing Address - Zip Code:45628-9573
Mailing Address - Country:US
Mailing Address - Phone:740-645-7779
Mailing Address - Fax:
Practice Address - Street 1:9180 STATE ROUTE 28
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:OH
Practice Address - Zip Code:45628-9573
Practice Address - Country:US
Practice Address - Phone:740-645-7779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376K00000X376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2649487Medicaid