Provider Demographics
NPI:1649738709
Name:CARLEN, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CARLEN
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 1:4957 VIRGINIA AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-4105
Mailing Address - Country:US
Mailing Address - Phone:320-333-3469
Mailing Address - Fax:
Practice Address - Street 1:7600 COUNTY ROAD 50
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MN
Practice Address - Zip Code:55373-8100
Practice Address - Country:US
Practice Address - Phone:763-477-5846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer