Provider Demographics
NPI:1639740384
Name:JUTRAS, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JUTRAS
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 1:968 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:POMFRET CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06259-2017
Mailing Address - Country:US
Mailing Address - Phone:860-539-8952
Mailing Address - Fax:
Practice Address - Street 1:113 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-4407
Practice Address - Country:US
Practice Address - Phone:704-735-1441
Practice Address - Fax:704-735-1472
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-05
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC349451163WP0200X
NC33U8W363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics