Provider Demographics
NPI:1093565954
Name:REGIS, AMANDA MICHELLE (LDO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:REGIS
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:
Other - Last Name:REGIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LDO
Mailing Address - Street 1:252 OAK AVENUE
Mailing Address - Street 2:120
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28081
Mailing Address - Country:US
Mailing Address - Phone:980-384-5412
Mailing Address - Fax:
Practice Address - Street 1:338 OAK AVENUE MALL DR
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28081-4340
Practice Address - Country:US
Practice Address - Phone:980-384-5412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1639156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician