Provider Demographics
NPI:1770053100
Name:AMUNDSON, ANNA-LIESE
Entity type:Individual
Prefix:
First Name:ANNA-LIESE
Middle Name:
Last Name:AMUNDSON
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 1:345 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-3039
Mailing Address - Country:US
Mailing Address - Phone:503-400-8234
Mailing Address - Fax:
Practice Address - Street 1:824 E JACKSON ST STE A
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6745
Practice Address - Country:US
Practice Address - Phone:458-225-9225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24474225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORBC000R3ROtherJACKSON CARE