Provider Demographics
NPI:1972180859
Name:FUTKOS, AMANDA M (RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:FUTKOS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7232 JUSTIN WAY
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4881
Mailing Address - Country:US
Mailing Address - Phone:440-578-8200
Mailing Address - Fax:
Practice Address - Street 1:7232 JUSTIN WAY
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4881
Practice Address - Country:US
Practice Address - Phone:440-578-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.426947163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0437829Medicaid