Provider Demographics
NPI:1891162426
Name:ANDERSON, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ANDERSON
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 1:518 13TH ST W
Mailing Address - Street 2:
Mailing Address - City:HARDIN
Mailing Address - State:MT
Mailing Address - Zip Code:59034-2401
Mailing Address - Country:US
Mailing Address - Phone:406-694-8307
Mailing Address - Fax:
Practice Address - Street 1:10110 S. 7650 E
Practice Address - Street 2:
Practice Address - City:CROW AGENCY
Practice Address - State:MT
Practice Address - Zip Code:59022-0009
Practice Address - Country:US
Practice Address - Phone:406-638-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-RN-LIC 45035163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse