Provider Demographics
NPI:1124425996
Name:IMMEL, AMANDA DAWN (RN)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:DAWN
Last Name:IMMEL
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 1:5 LIFE MARK DR
Mailing Address - Street 2:
Mailing Address - City:SELLERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18960-1577
Mailing Address - Country:US
Mailing Address - Phone:215-257-1155
Mailing Address - Fax:
Practice Address - Street 1:5 LIFE MARK DR
Practice Address - Street 2:
Practice Address - City:SELLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18960-1577
Practice Address - Country:US
Practice Address - Phone:215-257-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-22
Last Update Date:2014-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN650759163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse