Provider Demographics
NPI:1043670383
Name:EARL, AMANDA MARIE (LAC)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:MARIE
Last Name:EARL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-8223
Mailing Address - Country:US
Mailing Address - Phone:805-495-8300
Mailing Address - Fax:
Practice Address - Street 1:268 LOMBARD ST
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-8223
Practice Address - Country:US
Practice Address - Phone:805-495-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16930171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist