MEDICARE: MRS. AMANDA DIERKING BLISS MSN, RN, APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	1120706	KY
2	363LF0000X	Family Nurse Practitioner	3006098	KY
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	3006098	KY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00976196	OTHER	KY	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1225201288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANDA DIERKING BLISS MSN, RN, APRN

Provider Business Mailing Address
First Line	:	159 SAINT MATTHEWS AVE STE 8
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-3137
Country	:	US
Telephone Number	:	502-888-1494
Fax Number	:	502-237-6600

Provider Business Practice Location Address
First Line	:	159 SAINT MATTHEWS AVE STE 8
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-3137
Country	:	US
Telephone Number	:	502-888-1494
Fax Number	:	502-237-6600

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2008
Last Update Date	:	10/08/2024

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