Provider Demographics
NPI:1316030273
Name:LOVELADY JACKSON, AMANDA NICOLE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:NICOLE
Last Name:LOVELADY JACKSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:NICOLE
Other - Last Name:LOVELADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1402 20TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-5216
Mailing Address - Country:US
Mailing Address - Phone:256-654-1996
Mailing Address - Fax:
Practice Address - Street 1:1207 7TH STREET SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601
Practice Address - Country:US
Practice Address - Phone:256-341-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL75119367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered