Provider Demographics
NPI:1093965469
Name:DARNELL, AMANDA ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:DARNELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 JUDD RD
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MI
Mailing Address - Zip Code:48160-8913
Mailing Address - Country:US
Mailing Address - Phone:616-745-4424
Mailing Address - Fax:
Practice Address - Street 1:3601 WASHTENAW AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5277
Practice Address - Country:US
Practice Address - Phone:734-973-1969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004498152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI223498755Medicaid
MI223498755Medicare PIN