Provider Demographics
NPI:1588904114
Name:GINN, AMANDA NICOLE
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:NICOLE
Last Name:GINN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:NICOLE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 HAMILTON BR
Mailing Address - Street 2:
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179-6307
Mailing Address - Country:US
Mailing Address - Phone:606-796-9274
Mailing Address - Fax:
Practice Address - Street 1:40 HAMILTON BR
Practice Address - Street 2:
Practice Address - City:VANCEBURG
Practice Address - State:KY
Practice Address - Zip Code:41179-6307
Practice Address - Country:US
Practice Address - Phone:606-796-9274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist