Provider Demographics
NPI:1275908865
Name:HARVEY, AMANDA (RDH)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HARVEY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ROCHELLE
Other - Last Name:RALPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:554 KEILY STREET
Mailing Address - Street 2:BUREAU OF MEDICINE & SURGERY - CREDENTIALS AND PRIVILEG
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212
Mailing Address - Country:US
Mailing Address - Phone:757-953-7011
Mailing Address - Fax:
Practice Address - Street 1:554 KEILY STREET
Practice Address - Street 2:BUREAU OF MEDICINE & SURGERY - CREDENTIALS AND PRIVILEG
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212
Practice Address - Country:US
Practice Address - Phone:757-953-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402206767124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist