Provider Demographics
NPI:1417606302
Name:NIEVES, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NIEVES
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:PSC 473 BOX 47
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96349-0001
Mailing Address - Country:US
Mailing Address - Phone:315-241-8038
Mailing Address - Fax:
Practice Address - Street 1:82 INAOKACHO
Practice Address - Street 2:
Practice Address - City:YOKOSUKA
Practice Address - State:KANAGAWA
Practice Address - Zip Code:2380002
Practice Address - Country:JP
Practice Address - Phone:315-241-8038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-20
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101279604208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program