Provider Demographics
NPI:1114410404
Name:NETHERLY, AMANDA M
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:NETHERLY
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 1:289 JUPITER DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-6035
Mailing Address - Country:US
Mailing Address - Phone:513-549-2710
Mailing Address - Fax:
Practice Address - Street 1:289 JUPITER DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-6035
Practice Address - Country:US
Practice Address - Phone:513-549-2710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
201806900600156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH201806900600OtherGENERAL CONTRACTOR