Provider Demographics
NPI:1265997258
Name:ANDERSON, AMANDA NICOLE (DC)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3709 46TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2912
Mailing Address - Country:US
Mailing Address - Phone:715-614-0198
Mailing Address - Fax:
Practice Address - Street 1:101 LAKE ST W
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1576
Practice Address - Country:US
Practice Address - Phone:952-473-1773
Practice Address - Fax:844-235-6985
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6601111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor