Provider Demographics
NPI:1114356490
Name:ATHA, AMANDA LYNN
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:LYNN
Last Name:ATHA
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 1:3400 N CENTER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-7920
Mailing Address - Country:US
Mailing Address - Phone:989-792-1494
Mailing Address - Fax:989-249-9941
Practice Address - Street 1:3400 N CENTER RD STE 100
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-7920
Practice Address - Country:US
Practice Address - Phone:989-792-1494
Practice Address - Fax:989-249-9941
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704273153363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily