Provider Demographics
NPI:1255872933
Name:GOETHALS, AMANDA GLYNN (DO)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GLYNN
Last Name:GOETHALS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:300 20TH AVE N STE 403
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-5180
Mailing Address - Country:US
Mailing Address - Phone:615-284-4672
Mailing Address - Fax:
Practice Address - Street 1:7007 POWERS BOULEVARD
Practice Address - Street 2:UNIVERSITY PARMA MEDICAL CENTER
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129
Practice Address - Country:US
Practice Address - Phone:440-743-3006
Practice Address - Fax:440-743-2131
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
TN3933207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program