Provider Demographics
NPI:1467983858
Name:HANEY, AMANDA RAE (DO)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:RAE
Last Name:HANEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 JOEL DR
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5318
Mailing Address - Country:US
Mailing Address - Phone:270-798-8727
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-798-8727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-1980208D00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN