Provider Demographics
NPI:1518467562
Name:WETHERELL, AMANDA LEIGH
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:WETHERELL
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 1:411 WARNER BLVD
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-4343
Mailing Address - Country:US
Mailing Address - Phone:774-406-7658
Mailing Address - Fax:
Practice Address - Street 1:103 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3101
Practice Address - Country:US
Practice Address - Phone:508-521-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist