Provider Demographics
NPI:1578970422
Name:DAMON, AMANDA (CPNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DAMON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:GOODYKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PNP
Mailing Address - Street 1:2108 E THOMAS RD STE 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7761
Mailing Address - Country:US
Mailing Address - Phone:602-933-1813
Mailing Address - Fax:
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:029-330-8956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011648363LP0200X
AZ272758207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics