Provider Demographics
NPI:1396916433
Name:CLARK, AMANDA KAY (BS)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:KAY
Last Name:CLARK
Suffix:
Gender:F
Credentials:BS
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:KAY
Other - Last Name:WHIDDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:648 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-6311
Mailing Address - Country:US
Mailing Address - Phone:850-769-6001
Mailing Address - Fax:850-769-6003
Practice Address - Street 1:648 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-6311
Practice Address - Country:US
Practice Address - Phone:850-769-6001
Practice Address - Fax:850-769-6003
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker