Provider Demographics
NPI:1437700499
Name:MOEN, AMANDA SUE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUE
Last Name:MOEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:SUE
Other - Last Name:BECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 105TH ST NW
Mailing Address - Street 2:
Mailing Address - City:RICE
Mailing Address - State:MN
Mailing Address - Zip Code:56367-8656
Mailing Address - Country:US
Mailing Address - Phone:320-980-2630
Mailing Address - Fax:
Practice Address - Street 1:700 105TH ST NW
Practice Address - Street 2:
Practice Address - City:RICE
Practice Address - State:MN
Practice Address - Zip Code:56367-8656
Practice Address - Country:US
Practice Address - Phone:320-980-2630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-21
Last Update Date:2019-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1100892311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home