Provider Demographics
NPI:1528477353
Name:VAN DAALEN, AMANDA (OD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:VAN DAALEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5171 CITRUS BLVD STE 2040
Mailing Address - Street 2:
Mailing Address - City:HARAHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70123-2332
Mailing Address - Country:US
Mailing Address - Phone:504-818-0669
Mailing Address - Fax:
Practice Address - Street 1:5171 CITRUS BLVD STE 2040
Practice Address - Street 2:
Practice Address - City:HARAHAN
Practice Address - State:LA
Practice Address - Zip Code:70123-2332
Practice Address - Country:US
Practice Address - Phone:504-818-0669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1785-719T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist