Provider Demographics
NPI:1003417379
Name:DEOWDAT, AMANDA R
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:DEOWDAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7515 LYNDALE AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-4091
Mailing Address - Country:US
Mailing Address - Phone:651-269-1899
Mailing Address - Fax:
Practice Address - Street 1:7515 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-4091
Practice Address - Country:US
Practice Address - Phone:651-269-1899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist