Provider Demographics
NPI:1346872199
Name:HALVERSON, AMANDA (CRNA, DNAP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:CRNA, DNAP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3702 AUTOMATION WAY STE 103
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5738
Mailing Address - Country:US
Mailing Address - Phone:970-922-3622
Mailing Address - Fax:
Practice Address - Street 1:3702 AUTOMATION WAY STE 103
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5738
Practice Address - Country:US
Practice Address - Phone:970-922-3622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0995376367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty