Provider Demographics
NPI:1760722599
Name:AXON, AMANDA RAE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:AXON
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 1:10698 METCALF RD
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:MI
Mailing Address - Zip Code:48097-4511
Mailing Address - Country:US
Mailing Address - Phone:810-304-1114
Mailing Address - Fax:
Practice Address - Street 1:1001 MILITARY ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5416
Practice Address - Country:US
Practice Address - Phone:810-985-5437
Practice Address - Fax:180-024-8156
Is Sole Proprietor?:No
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI372600000XOtherADULT COMPANION