Provider Demographics
NPI:1295301851
Name:AMB, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:AMB
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 1:14068 4TH ST NE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ND
Mailing Address - Zip Code:58274-9234
Mailing Address - Country:US
Mailing Address - Phone:701-430-9135
Mailing Address - Fax:
Practice Address - Street 1:14068 4TH ST NE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ND
Practice Address - Zip Code:58274-9234
Practice Address - Country:US
Practice Address - Phone:701-430-9135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND874756Medicaid