Provider Demographics
NPI:1386794972
Name:ANDERSON, AMANDA M
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:M
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 1:1142 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-3628
Mailing Address - Country:US
Mailing Address - Phone:440-964-3013
Mailing Address - Fax:
Practice Address - Street 1:1142 E 15TH ST
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-3628
Practice Address - Country:US
Practice Address - Phone:440-964-3013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2654337Medicaid