Provider Demographics
NPI:1922381383
Name:BOTKIN, AMANDA MARIE (ANP)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:MARIE
Last Name:BOTKIN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8064
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-996-6065
Mailing Address - Fax:314-996-6074
Practice Address - Street 1:3023 N BALLAS RD
Practice Address - Street 2:STE 450 BLDG D
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2330
Practice Address - Country:US
Practice Address - Phone:314-996-6065
Practice Address - Fax:314-996-6074
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011028684363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health