Provider Demographics
NPI:1982034237
Name:NIEDERHAUSER, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NIEDERHAUSER
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 1:9070 CHARITY DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7368
Mailing Address - Country:US
Mailing Address - Phone:719-200-6832
Mailing Address - Fax:
Practice Address - Street 1:1970 DOMINION WAY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1465
Practice Address - Country:US
Practice Address - Phone:719-200-6832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-23
Last Update Date:2013-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0014165171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor