Provider Demographics
NPI:1790493609
Name:TEDFORD, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:TEDFORD
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 1:7916 NW 23RD ST # 127
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-4950
Mailing Address - Country:US
Mailing Address - Phone:405-245-6595
Mailing Address - Fax:
Practice Address - Street 1:4055 VALLEY VIEW LANE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244
Practice Address - Country:US
Practice Address - Phone:405-245-6595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK205704363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily