Provider Demographics
NPI:1841520251
Name:HARRIS, AMANDA (LPN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7311 STATE HIGHWAY 5
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13452-4203
Mailing Address - Country:US
Mailing Address - Phone:315-717-7124
Mailing Address - Fax:
Practice Address - Street 1:7311 STATE HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:SAINT JOHNSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13452-4203
Practice Address - Country:US
Practice Address - Phone:315-717-7124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2999151164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse