Provider Demographics
NPI:1366038382
Name:RAMOS, AMANDA NICHOLE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICHOLE
Last Name:RAMOS
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 1:1345 BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-1416
Mailing Address - Country:US
Mailing Address - Phone:541-767-4170
Mailing Address - Fax:547-942-9310
Practice Address - Street 1:1345 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-1416
Practice Address - Country:US
Practice Address - Phone:541-767-4170
Practice Address - Fax:547-942-9310
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist