Provider Demographics
NPI:1902413495
Name:LY, AMANDA (OD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3164 HIGHLANDER RD
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-5508
Mailing Address - Country:US
Mailing Address - Phone:714-515-2571
Mailing Address - Fax:
Practice Address - Street 1:43927 15TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4758
Practice Address - Country:US
Practice Address - Phone:661-948-6310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT34702-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist