Provider Demographics
NPI:1578795886
Name:KING, AMANDA GAYE (RPSGT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GAYE
Last Name:KING
Suffix:
Gender:F
Credentials:RPSGT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 ELMWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-1540
Mailing Address - Country:US
Mailing Address - Phone:517-944-0143
Mailing Address - Fax:
Practice Address - Street 1:1312 ELMWOOD RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-1540
Practice Address - Country:US
Practice Address - Phone:517-944-0143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI8202246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic