Provider Demographics
NPI:1154641363
Name:GAITAUD, AMANDA MARIE (LAC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:GAITAUD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1617
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:95258-1617
Mailing Address - Country:US
Mailing Address - Phone:209-369-5008
Mailing Address - Fax:
Practice Address - Street 1:1121 W VINE ST STE 14
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5137
Practice Address - Country:US
Practice Address - Phone:209-369-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13469171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist