Provider Demographics
NPI:1104362250
Name:HALLEY, AMANDA SUE (RN)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:SUE
Last Name:HALLEY
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 1:722 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-2014
Mailing Address - Country:US
Mailing Address - Phone:636-390-3147
Mailing Address - Fax:
Practice Address - Street 1:722 W 8TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-2014
Practice Address - Country:US
Practice Address - Phone:636-390-3147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010026695163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse