Provider Demographics
NPI:1295233146
Name:ANDERSON, AMANDA DAWN (LVN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DAWN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21578 FM 343
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:TX
Mailing Address - Zip Code:75760-4941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:FM 347
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766
Practice Address - Country:US
Practice Address - Phone:936-585-0455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210598164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse