Provider Demographics
NPI:1073212122
Name:ANDERSON, AMANDA CHANTELL
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CHANTELL
Last Name:ANDERSON
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 1:7801 OLD BRANCH AVE
Mailing Address - Street 2:UNIT 300 #13
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735
Mailing Address - Country:US
Mailing Address - Phone:301-381-1666
Mailing Address - Fax:
Practice Address - Street 1:7801 OLD BRANCH AVE
Practice Address - Street 2:UNIT 300 #13
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735
Practice Address - Country:US
Practice Address - Phone:301-381-1666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD82-1428313OtherPROSTHETIC/ORTHOTIC SUPPLIER