Provider Demographics
NPI:1124479324
Name:KNITTEL, AMANDA NICOLE
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:NICOLE
Last Name:KNITTEL
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:AMANDA
Other - Middle Name:NICOLE
Other - Last Name:LIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1105 N 31ST ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-1886
Mailing Address - Country:US
Mailing Address - Phone:918-896-3821
Mailing Address - Fax:
Practice Address - Street 1:1105 N 31ST ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-1886
Practice Address - Country:US
Practice Address - Phone:918-896-3821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program