Provider Demographics
NPI:1164857645
Name:MACKELLAR, AMANDA LEIGH (RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:MACKELLAR
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEIGH
Other - Last Name:BLAIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:25 REJANE AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-2513
Mailing Address - Country:US
Mailing Address - Phone:207-576-3629
Mailing Address - Fax:
Practice Address - Street 1:25 REJANE AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-2513
Practice Address - Country:US
Practice Address - Phone:207-576-3629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN61661163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse