Provider Demographics
NPI:1093074262
Name:PETERMAN, AMANDA RUTH (LPN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RUTH
Last Name:PETERMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2262 FILLMANS BOTTOM RD SW
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43837-9134
Mailing Address - Country:US
Mailing Address - Phone:330-447-3263
Mailing Address - Fax:
Practice Address - Street 1:2219 N WATER STREET EXT
Practice Address - Street 2:
Practice Address - City:UHRICHSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44683-1049
Practice Address - Country:US
Practice Address - Phone:330-447-3263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN141408 M IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse