Provider Demographics
NPI:1730753005
Name:CERDA KOCH, AMANDA (LVN)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:CERDA KOCH
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 1:1142 LILAC LEDGE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-2178
Mailing Address - Country:US
Mailing Address - Phone:956-223-7293
Mailing Address - Fax:
Practice Address - Street 1:36065 SANTE FE AVE
Practice Address - Street 2:
Practice Address - City:FT. HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-553-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX193001164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse