Provider Demographics
NPI:1982204863
Name:KOM, AMBER LEA
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LEA
Last Name:KOM
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 1:9988 HWY 281
Mailing Address - Street 2:
Mailing Address - City:DUNSEITH
Mailing Address - State:ND
Mailing Address - Zip Code:58329
Mailing Address - Country:US
Mailing Address - Phone:701-263-6573
Mailing Address - Fax:
Practice Address - Street 1:9988 HWY 281
Practice Address - Street 2:
Practice Address - City:DUNSEITH
Practice Address - State:ND
Practice Address - Zip Code:58329
Practice Address - Country:US
Practice Address - Phone:701-263-6573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1464193Medicaid