Provider Demographics
NPI:1306045539
Name:DWORSKI, AMANDA (RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DWORSKI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 23RD ST
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4363
Mailing Address - Country:US
Mailing Address - Phone:970-945-1234
Mailing Address - Fax:
Practice Address - Street 1:401 23RD ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4363
Practice Address - Country:US
Practice Address - Phone:970-945-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO130665163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45906025Medicaid