Provider Demographics
NPI:1639791304
Name:BLANDFORD, AMANDA MARIE (ND)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:MARIE
Last Name:BLANDFORD
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 TEASEL ST NE
Mailing Address - Street 2:
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-9599
Mailing Address - Country:US
Mailing Address - Phone:616-301-4214
Mailing Address - Fax:
Practice Address - Street 1:4655 14 MILE RD NE STE B
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-7308
Practice Address - Country:US
Practice Address - Phone:616-884-0645
Practice Address - Fax:616-884-0646
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT61008474175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
WANT61008474OtherNATUROPATHIC PHYSICIAN LICENSE