Provider Demographics
NPI:1245006998
Name:WHITTAKER, AMANDA LYNN (LDO)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 GEORGESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-3327
Mailing Address - Country:US
Mailing Address - Phone:614-275-9840
Mailing Address - Fax:614-275-9847
Practice Address - Street 1:1221 GEORGESVILLE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-3327
Practice Address - Country:US
Practice Address - Phone:614-275-9840
Practice Address - Fax:614-275-9847
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.017564-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician