Provider Demographics
NPI:1710510862
Name:BACKSTROM, AMANDA E
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:E
Last Name:BACKSTROM
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 1:27 BIRCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EAST TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02718-1501
Mailing Address - Country:US
Mailing Address - Phone:774-285-3479
Mailing Address - Fax:
Practice Address - Street 1:131 SUMMER ST
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02325-0001
Practice Address - Country:US
Practice Address - Phone:774-285-3479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program