Provider Demographics
NPI:1851749881
Name:DEHART, AMANDA LEA (RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEA
Last Name:DEHART
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEA
Other - Last Name:COPE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP
Mailing Address - Street 1:5060 SHOREHAM PL STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-5904
Mailing Address - Country:US
Mailing Address - Phone:619-221-0344
Mailing Address - Fax:
Practice Address - Street 1:5060 SHOREHAM PL STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5904
Practice Address - Country:US
Practice Address - Phone:619-221-0344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA828346163WP0809X
CA95026676363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult