Provider Demographics
NPI:1063964765
Name:PITTMAN, AMANDA VICTORIA (LM, CPM)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:VICTORIA
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 43 1/2 AVE NE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-3022
Mailing Address - Country:US
Mailing Address - Phone:352-871-2371
Mailing Address - Fax:
Practice Address - Street 1:968 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3014
Practice Address - Country:US
Practice Address - Phone:651-895-2520
Practice Address - Fax:651-330-3768
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-28
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW342176B00000X
MN1071176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife