Provider Demographics
NPI:1275657868
Name:ROE, AMANDA ELIZABETH (LPN)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:ROE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 MAIN ST
Mailing Address - Street 2:LOT 3
Mailing Address - City:WORCESTER
Mailing Address - State:NY
Mailing Address - Zip Code:12197-1930
Mailing Address - Country:US
Mailing Address - Phone:607-434-7422
Mailing Address - Fax:
Practice Address - Street 1:755 CASE RD
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:13733-3197
Practice Address - Country:US
Practice Address - Phone:607-967-4858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282889-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse