Provider Demographics
NPI:1750133476
Name:JUSTICE, AMANDA SUE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUE
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-2723
Mailing Address - Country:US
Mailing Address - Phone:330-389-3965
Mailing Address - Fax:
Practice Address - Street 1:624 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-2723
Practice Address - Country:US
Practice Address - Phone:330-389-3965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty