Provider Demographics
NPI:1235486952
Name:BREEDLOVE, AMANDA NICOLE (PNP)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:NICOLE
Last Name:BREEDLOVE
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 SMIZER MILL RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-3483
Mailing Address - Country:US
Mailing Address - Phone:636-717-1414
Mailing Address - Fax:
Practice Address - Street 1:1203 SMIZER MILL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-3483
Practice Address - Country:US
Practice Address - Phone:636-717-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012026927363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics