Provider Demographics
NPI:1831733419
Name:FAMBROUGH, AMANDA BETH
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:BETH
Last Name:FAMBROUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:BETH
Other - Last Name:BLOMGREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2015 W BROADWAY ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2560
Mailing Address - Country:US
Mailing Address - Phone:580-448-2626
Mailing Address - Fax:580-262-4274
Practice Address - Street 1:2015 W BROADWAY ST STE 2C
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2560
Practice Address - Country:US
Practice Address - Phone:580-448-2626
Practice Address - Fax:580-262-4274
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKCF548235Z00000X
OK6199235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist