Provider Demographics
NPI:1255626073
Name:DEWAR, AMANDA ANN
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANN
Last Name:DEWAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ANN
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4 ENTERPRISE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ISANTI
Mailing Address - State:MN
Mailing Address - Zip Code:55040-6813
Mailing Address - Country:US
Mailing Address - Phone:763-552-6161
Mailing Address - Fax:763-237-3254
Practice Address - Street 1:4 ENTERPRISE AVE NE
Practice Address - Street 2:
Practice Address - City:ISANTI
Practice Address - State:MN
Practice Address - Zip Code:55040-6813
Practice Address - Country:US
Practice Address - Phone:763-552-6161
Practice Address - Fax:763-237-3254
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist