Provider Demographics
NPI:1437823077
Name:SHUPE, AMANDA KAY (LPN)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:KAY
Last Name:SHUPE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KAY
Other - Last Name:DYKHOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:470 BALTIMORE DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:470 BALTIMORE DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3934
Practice Address - Country:US
Practice Address - Phone:616-890-8364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703107868164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse