Provider Demographics
NPI:1871184010
Name:CANADA, AMANDA (PHD, DNP, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:CANADA
Suffix:
Gender:F
Credentials:PHD, DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8817 MARTIN WAY E APT 108
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-6808
Mailing Address - Country:US
Mailing Address - Phone:210-563-3299
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:210-563-3299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-31
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX772141163W00000X
WAAP61321289363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse