Provider Demographics
NPI:1629723192
Name:HARVARD, AMANDA NICOLE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:HARVARD
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 1:1175 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-9301
Mailing Address - Country:US
Mailing Address - Phone:248-672-6755
Mailing Address - Fax:
Practice Address - Street 1:4800 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2677
Practice Address - Country:US
Practice Address - Phone:810-213-8144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011389363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty