Provider Demographics
NPI:1710317011
Name:DAVIS, AMANDA LARUE (RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LARUE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 S FM 706
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-0201
Mailing Address - Country:US
Mailing Address - Phone:936-635-0309
Mailing Address - Fax:936-632-6127
Practice Address - Street 1:132 S FM 706
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-0201
Practice Address - Country:US
Practice Address - Phone:936-635-0309
Practice Address - Fax:936-632-6127
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-22
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX793269171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator