Provider Demographics
NPI:1588164891
Name:YOUNG, AMANDA (SERVICES FACILITATOR)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:SERVICES FACILITATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-0776
Mailing Address - Country:US
Mailing Address - Phone:434-575-5200
Mailing Address - Fax:434-575-5054
Practice Address - Street 1:606 BROAD ST STE F
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-3200
Practice Address - Country:US
Practice Address - Phone:434-575-5200
Practice Address - Fax:434-575-5054
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1619053667Medicaid