Provider Demographics
NPI:1205660230
Name:BOGGS, AMANDA ROSE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:BOGGS
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 1:424 N HALLETT ST
Mailing Address - Street 2:
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-9006
Mailing Address - Country:US
Mailing Address - Phone:509-844-8300
Mailing Address - Fax:
Practice Address - Street 1:424 N HALLETT ST
Practice Address - Street 2:
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022-9006
Practice Address - Country:US
Practice Address - Phone:509-844-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61355879225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist