Provider Demographics
NPI:1598238909
Name:SERVOSS, AMANDA DEYANIRA (RN BSN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DEYANIRA
Last Name:SERVOSS
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 E CROSSTOWN PKWY
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-2501
Mailing Address - Country:US
Mailing Address - Phone:269-553-7089
Mailing Address - Fax:
Practice Address - Street 1:615 E CROSSTOWN PKWY
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-2501
Practice Address - Country:US
Practice Address - Phone:269-553-7089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704335693163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health