Provider Demographics
NPI:1225201288
Name:BLISS, AMANDA DIERKING (MSN, RN, APRN)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:DIERKING
Last Name:BLISS
Suffix:
Gender:F
Credentials:MSN, RN, APRN
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:JEANNE
Other - Last Name:DIERKING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, APRN
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:6400 DUTCHMANS PKWY STE 205
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3343
Practice Address - Country:US
Practice Address - Phone:888-442-4325
Practice Address - Fax:502-966-5948
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2023-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX852185163W00000X
TXAP125268363LF0000X
KY3006098363LF0000X, 363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00976196OtherRAILROAD MEDICARE
KYK013750Medicare PIN