Provider Demographics
NPI:1386216885
Name:MACKNER, AMANDA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:MARIE
Last Name:MACKNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4360 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3310
Mailing Address - Country:US
Mailing Address - Phone:701-282-5880
Mailing Address - Fax:
Practice Address - Street 1:4360 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3310
Practice Address - Country:US
Practice Address - Phone:701-282-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2935152W00000X
WI3852-35152W00000X
MN3730152W00000X
ND799152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist