MEDICARE: MRS. AMANDA STAGGERS

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	374U00000X	Home Health Aide

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	K02324995	OTHER	KS	DRIVERS LICENSE

General Provider Information

NPI Number	:	1386125912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANDA STAGGERS

Provider Business Mailing Address
First Line	:	1504 AVENUE K APT 112
Second Line	:
City	:	DODGE CITY
State	:	KS
Zip	:	67801-7124
Country	:	US
Telephone Number	:	843-591-9848
Fax Number	:

Provider Business Practice Location Address
First Line	:	1504 AVENUE K APT 112
Second Line	:
City	:	DODGE CITY
State	:	KS
Zip	:	67801-7124
Country	:	US
Telephone Number	:	843-591-9848
Fax Number	:

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

Provider Enumeration Date	:	08/22/2018
Last Update Date	:	08/22/2018

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