Provider Demographics
NPI:1821252800
Name:LOVOLD, AMANDA LEA (DO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEA
Last Name:LOVOLD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 WHITNEY CT
Mailing Address - Street 2:CENTRACARE CLINIC-HEARTLAND FAMILY MEDICINE
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56703-1899
Mailing Address - Country:US
Mailing Address - Phone:320-251-1775
Mailing Address - Fax:
Practice Address - Street 1:1520 WHITNEY CT
Practice Address - Street 2:CENTRACARE CLINIC-HEARTLAND FAMILY MEDICINE
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56703-1899
Practice Address - Country:US
Practice Address - Phone:320-251-1775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
IAENROLLEDMedicaid