Provider Demographics
NPI:1699055889
Name:ORTLIEB, AMANDA (LPN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ORTLIEB
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 MIDDLEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-0107
Mailing Address - Country:US
Mailing Address - Phone:315-866-7932
Mailing Address - Fax:
Practice Address - Street 1:703 MIDDLEVILLE RD
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-0107
Practice Address - Country:US
Practice Address - Phone:315-866-7932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306448-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse