Provider Demographics
NPI:1467095422
Name:REID, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:REID
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 1:3518 S WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3665
Mailing Address - Country:US
Mailing Address - Phone:765-860-6012
Mailing Address - Fax:
Practice Address - Street 1:186 E SOUTHWAY BLVD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3650
Practice Address - Country:US
Practice Address - Phone:765-236-8299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28210688A363LF0000X
IN71009489A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty