Provider Demographics
NPI:1770362543
Name:BOCANEGRA, AMANDA (CCSH)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BOCANEGRA
Suffix:
Gender:F
Credentials:CCSH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14270 GEDDES RD
Mailing Address - Street 2:
Mailing Address - City:HEMLOCK
Mailing Address - State:MI
Mailing Address - Zip Code:48626-9466
Mailing Address - Country:US
Mailing Address - Phone:989-274-5648
Mailing Address - Fax:
Practice Address - Street 1:3515 COOLIDGE RD STE A
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8014
Practice Address - Country:US
Practice Address - Phone:517-755-6888
Practice Address - Fax:517-657-7759
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1214174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator