Provider Demographics
NPI:1225629900
Name:LEWALLEN, AMANDA REN'EE (AA, AS, OTA)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:REN'EE
Last Name:LEWALLEN
Suffix:
Gender:F
Credentials:AA, AS, OTA
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:REN'EE
Other - Last Name:FRALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7922 EMERSON RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:OH
Mailing Address - Zip Code:43466-9721
Mailing Address - Country:US
Mailing Address - Phone:567-213-1557
Mailing Address - Fax:
Practice Address - Street 1:7922 EMERSON RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:OH
Practice Address - Zip Code:43466-9721
Practice Address - Country:US
Practice Address - Phone:567-213-1557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide