Provider Demographics
NPI:1942561964
Name:SCOTT, AMANDA CATHERINE (ANP)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:CATHERINE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:CATHERINE
Other - Last Name:JANISSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:3779 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5337
Mailing Address - Country:US
Mailing Address - Phone:989-366-2900
Mailing Address - Fax:
Practice Address - Street 1:2585 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-9624
Practice Address - Country:US
Practice Address - Phone:989-366-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704217937363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health