Provider Demographics
NPI:1417331778
Name:HANSEN, AMANDA (CERTIFICATE)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:CERTIFICATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 N MAIN ST APT 6
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2572
Mailing Address - Country:US
Mailing Address - Phone:307-620-5901
Mailing Address - Fax:
Practice Address - Street 1:1923 N MAIN ST APT 6
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2572
Practice Address - Country:US
Practice Address - Phone:307-620-5901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY184483407174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator