Provider Demographics
NPI:1407190671
Name:ALLAIRE, AMANDA J (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:ALLAIRE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 WILLOWAY RD
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-4970
Mailing Address - Country:US
Mailing Address - Phone:414-897-2435
Mailing Address - Fax:
Practice Address - Street 1:380 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-725-0900
Practice Address - Fax:208-725-0901
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-12
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1618A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2012001190OtherANCC