Provider Demographics
NPI:1659842763
Name:WOODLE STEWART, AMANDA DAWN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DAWN
Last Name:WOODLE STEWART
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 1:75 EMMA CT
Mailing Address - Street 2:
Mailing Address - City:BOALSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16827-1454
Mailing Address - Country:US
Mailing Address - Phone:814-574-3637
Mailing Address - Fax:
Practice Address - Street 1:110 ROLLING RIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:BOALSBURG
Practice Address - State:PA
Practice Address - Zip Code:16827
Practice Address - Country:US
Practice Address - Phone:814-231-8399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP44486183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist