Provider Demographics
NPI:1649496589
Name:MAMENKO, AMY MARIE (LPN)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:MAMENKO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:MAMENKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:127 WEDGEFIELD DR
Mailing Address - Street 2:EAGLE GLEN
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-3737
Mailing Address - Country:US
Mailing Address - Phone:302-395-4025
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD STE 240
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-2225
Practice Address - Country:US
Practice Address - Phone:302-998-0469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL2-0008389164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse