Provider Demographics
NPI:1386467694
Name:DILLON, AMANDA (PRSS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DILLON
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3544 4TH AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-2038
Mailing Address - Country:US
Mailing Address - Phone:304-881-6825
Mailing Address - Fax:
Practice Address - Street 1:1303 WASHINGTON ST W
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-1333
Practice Address - Country:US
Practice Address - Phone:304-553-0010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor