Provider Demographics
NPI:1073198685
Name:MCCANN, AMANDA M (RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:MCCANN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 12TH ST N
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-3525
Mailing Address - Country:US
Mailing Address - Phone:701-640-1294
Mailing Address - Fax:
Practice Address - Street 1:1484 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1032
Practice Address - Country:US
Practice Address - Phone:218-736-5565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN195528-0163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice