Provider Demographics
NPI:1376119545
Name:ELAM, AMANDA ROSE (CNM)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:ELAM
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE BOX 668
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-7892
Mailing Address - Fax:
Practice Address - Street 1:909 CULVER RD STE 2B
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-7141
Practice Address - Country:US
Practice Address - Phone:585-276-9388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2074207RH0003X
NY002074367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology