Provider Demographics
NPI:1194399253
Name:YOUNG, AMANDA R
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:YOUNG
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 1:1560 BETTY CT
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-4405
Mailing Address - Country:US
Mailing Address - Phone:707-298-1556
Mailing Address - Fax:
Practice Address - Street 1:1560 BETTY CT
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-4405
Practice Address - Country:US
Practice Address - Phone:707-298-1556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2023-01-26
Deactivation Date:2021-05-25
Deactivation Code:
Reactivation Date:2021-06-16
Provider Licenses
StateLicense IDTaxonomies
390200000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program