Provider Demographics
NPI:1710567656
Name:PETTERSON, AMANDA (CPHT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PETTERSON
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 SHERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-3528
Mailing Address - Country:US
Mailing Address - Phone:325-942-0454
Mailing Address - Fax:
Practice Address - Street 1:3301 SHERWOOD WAY
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3528
Practice Address - Country:US
Practice Address - Phone:325-942-0454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX276908183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician