Provider Demographics
NPI:1881217065
Name:KING, AMANDA LAINE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LAINE
Last Name:KING
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:PO BOX 3414
Mailing Address - Street 2:
Mailing Address - City:EARLY
Mailing Address - State:TX
Mailing Address - Zip Code:76803-3414
Mailing Address - Country:US
Mailing Address - Phone:325-998-2099
Mailing Address - Fax:
Practice Address - Street 1:1511 EARLY BLVD
Practice Address - Street 2:
Practice Address - City:EARLY
Practice Address - State:TX
Practice Address - Zip Code:76802-2317
Practice Address - Country:US
Practice Address - Phone:325-998-2099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX944312163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse