Provider Demographics
NPI:1912250861
Name:NIXON, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NIXON
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:PO BOX 74
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:MI
Mailing Address - Zip Code:49688-0074
Mailing Address - Country:US
Mailing Address - Phone:231-465-4165
Mailing Address - Fax:231-465-4315
Practice Address - Street 1:202 S HOWARD ST
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:MI
Practice Address - Zip Code:49688-5123
Practice Address - Country:US
Practice Address - Phone:231-465-4165
Practice Address - Fax:231-465-4315
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006530363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical