Provider Demographics
NPI:1316498132
Name:BOATWRIGHT, AMANDA JO
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:BOATWRIGHT
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 1:460 TULIP
Mailing Address - Street 2:
Mailing Address - City:SCOTT CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63780-8200
Mailing Address - Country:US
Mailing Address - Phone:618-973-5580
Mailing Address - Fax:
Practice Address - Street 1:371 S BROADVIEW ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5761
Practice Address - Country:US
Practice Address - Phone:573-331-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016008595363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily