Provider Demographics
NPI:1023580412
Name:JANZEN, AMANDA (IBCLC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JANZEN
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:DEFORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1525 RURAL ST
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-5545
Mailing Address - Country:US
Mailing Address - Phone:620-222-8514
Mailing Address - Fax:
Practice Address - Street 1:1525 RURAL ST
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-5545
Practice Address - Country:US
Practice Address - Phone:620-222-8514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-22
Last Update Date:2018-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSL-108233163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant