Provider Demographics
NPI:1487955316
Name:LARSON, AMANDA NICOLE (IDC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:LARSON
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:NICOLE
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IDC
Mailing Address - Street 1:500 CENTER ST
Mailing Address - Street 2:BUILDING 22
Mailing Address - City:WAHIAWA
Mailing Address - State:HI
Mailing Address - Zip Code:96786-3007
Mailing Address - Country:US
Mailing Address - Phone:228-760-0296
Mailing Address - Fax:
Practice Address - Street 1:500 CENTER ST
Practice Address - Street 2:BUILDING 22
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786-3007
Practice Address - Country:US
Practice Address - Phone:228-760-0296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman