Provider Demographics
NPI:1851914394
Name:MCCOMMON, AMANDA
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:MCCOMMON
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 1:2119 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5023
Mailing Address - Country:US
Mailing Address - Phone:307-214-9513
Mailing Address - Fax:
Practice Address - Street 1:2119 E 18TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5023
Practice Address - Country:US
Practice Address - Phone:307-214-9513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health