Provider Demographics
NPI:1528646221
Name:GRANTHAM, AMANDA (LPN, NBC-HWC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:LPN, NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1999 SCARLETT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34289-9400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5520 E STATE ROAD 64 STE 101
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-5526
Practice Address - Country:US
Practice Address - Phone:941-721-0649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach