Provider Demographics
NPI:1194349100
Name:AMOS, AMANDA (BA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:AMOS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 EUSTIS ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-5105
Mailing Address - Country:US
Mailing Address - Phone:651-231-3782
Mailing Address - Fax:
Practice Address - Street 1:2103 COUNTY ROAD D E STE B
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-5358
Practice Address - Country:US
Practice Address - Phone:651-748-5019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program