Provider Demographics
NPI:1912536871
Name:AMANI, ICE (DO)
Entity Type:Individual
Prefix:
First Name:ICE
Middle Name:
Last Name:AMANI
Suffix:
Gender:M
Credentials:DO
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1995 WELLNESS BLVD STE 110&210
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-7769
Practice Address - Country:US
Practice Address - Phone:704-384-1140
Practice Address - Fax:704-384-1141
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2023-09-18
Deactivation Date:2023-06-30
Deactivation Code:
Reactivation Date:2023-08-02
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2023-02405207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program