Provider Demographics
NPI:1497398465
Name:BURDETT-CRUZ, AMANDA MICHELLE (LVN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:BURDETT-CRUZ
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MICHELLE
Other - Last Name:CRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:5137 OLD SPANISH TRL
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77807-7697
Mailing Address - Country:US
Mailing Address - Phone:979-676-2697
Mailing Address - Fax:
Practice Address - Street 1:5137 OLD SPANISH TRL
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77807-7697
Practice Address - Country:US
Practice Address - Phone:979-676-2697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX186098208000000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No208000000XAllopathic & Osteopathic PhysiciansPediatrics