Provider Demographics
NPI:1194091355
Name:ANDERSON, AMANDA MICHELLE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14951 WALDEN SPRING WAY
Mailing Address - Street 2:#602
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-1184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14951 WALDEN SPRING WAY
Practice Address - Street 2:#602
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-1184
Practice Address - Country:US
Practice Address - Phone:904-583-4361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-31
Last Update Date:2012-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor