Provider Demographics
NPI:1851644371
Name:MENARY, AMANDA JOHANNA
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:JOHANNA
Last Name:MENARY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:JOHANNA
Other - Last Name:AARON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:612 PALOMINO DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5409
Mailing Address - Country:US
Mailing Address - Phone:707-484-3411
Mailing Address - Fax:707-576-7845
Practice Address - Street 1:1901 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4282
Practice Address - Country:US
Practice Address - Phone:707-576-0818
Practice Address - Fax:707-576-7845
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36689167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician