Provider Demographics
NPI:1467223685
Name:SOUDOM, AMANDA (APRN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SOUDOM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 WILLETTS BOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:BATTLETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40104-7316
Mailing Address - Country:US
Mailing Address - Phone:502-475-1038
Mailing Address - Fax:
Practice Address - Street 1:1600 WILLETTS BOTTOM RD
Practice Address - Street 2:
Practice Address - City:BATTLETOWN
Practice Address - State:KY
Practice Address - Zip Code:40104-7316
Practice Address - Country:US
Practice Address - Phone:502-475-1038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4015068363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty