Provider Demographics
NPI:1669978623
Name:RENO, AMANDA (DO)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:RENO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 MILLPOND STE 100
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9760
Mailing Address - Country:US
Mailing Address - Phone:435-843-3000
Mailing Address - Fax:
Practice Address - Street 1:220 MILLPOND STE 100
Practice Address - Street 2:
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-9760
Practice Address - Country:US
Practice Address - Phone:435-843-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO.2126208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics