Provider Demographics
NPI:1346851466
Name:VANTASSELL, AMBER LYNN
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LYNN
Last Name:VANTASSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 MIRACLE RUN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:WV
Mailing Address - Zip Code:26570-6049
Mailing Address - Country:US
Mailing Address - Phone:304-291-3345
Mailing Address - Fax:
Practice Address - Street 1:97 MIRACLE RUN RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:WV
Practice Address - Zip Code:26570-6049
Practice Address - Country:US
Practice Address - Phone:304-291-3345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant