Provider Demographics
NPI:1902400393
Name:ROSE, AMANDA KAY
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAY
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KAY
Other - Last Name:MCKINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50 YELLOW PINE LN
Mailing Address - Street 2:
Mailing Address - City:MAYSEL
Mailing Address - State:WV
Mailing Address - Zip Code:25133-9748
Mailing Address - Country:US
Mailing Address - Phone:304-587-7071
Mailing Address - Fax:
Practice Address - Street 1:15 BANK ST
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043
Practice Address - Country:US
Practice Address - Phone:304-587-9992
Practice Address - Fax:304-587-9993
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant