Provider Demographics
NPI:1912192915
Name:BOIVIN, AMANDA ANNE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANNE
Last Name:BOIVIN
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 1:4696 PAULETTE PL
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-7553
Mailing Address - Country:US
Mailing Address - Phone:707-481-0978
Mailing Address - Fax:
Practice Address - Street 1:4696 PAULETTE PL
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7553
Practice Address - Country:US
Practice Address - Phone:707-481-0978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer