Provider Demographics
NPI:1164409124
Name:JOHN, AMANDA SUE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:SUE
Last Name:JOHN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1822
Mailing Address - Country:US
Mailing Address - Phone:220-564-4226
Mailing Address - Fax:220-564-4217
Practice Address - Street 1:1320 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1822
Practice Address - Country:US
Practice Address - Phone:220-564-4226
Practice Address - Fax:220-564-4217
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA-12359-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0053321Medicaid
OHH028161Medicare PIN