Provider Demographics
NPI:1164049698
Name:BEN, AMANDA J
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:BEN
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 1:23 TERRE VERTE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-1217
Mailing Address - Country:US
Mailing Address - Phone:716-228-0524
Mailing Address - Fax:
Practice Address - Street 1:23 TERRE VERTE CT
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-1217
Practice Address - Country:US
Practice Address - Phone:716-228-0524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020003743363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily