Provider Demographics
NPI:1740641661
Name:KING, AMANDA RENEE (DO)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RENEE
Last Name:KING
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 1:5515 BLUE DIAMOND ROAD
Mailing Address - Street 2:SUITE 102 PMB 1011
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139
Mailing Address - Country:US
Mailing Address - Phone:317-450-3454
Mailing Address - Fax:317-647-4311
Practice Address - Street 1:526 S TONOPAH DR STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4013
Practice Address - Country:US
Practice Address - Phone:702-440-8430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-20
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NVDO29852084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program