Provider Demographics
NPI:1891383873
Name:BOOTH, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BOOTH
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 811
Mailing Address - Street 2:
Mailing Address - City:CABIN CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:25035-0811
Mailing Address - Country:US
Mailing Address - Phone:304-380-1504
Mailing Address - Fax:
Practice Address - Street 1:325 4TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1266
Practice Address - Country:US
Practice Address - Phone:304-744-4940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant