Provider Demographics
NPI:1629419742
Name:O/BRYAN, AMANDA DAWN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DAWN
Last Name:O/BRYAN
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 1:500 W SUSAN PL
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-2896
Mailing Address - Country:US
Mailing Address - Phone:417-439-8343
Mailing Address - Fax:
Practice Address - Street 1:214 W 5TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-2598
Practice Address - Country:US
Practice Address - Phone:417-782-2917
Practice Address - Fax:417-782-7038
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007001110163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse