Healthcare Provider Details

I. General information

NPI: 1942549506
Provider Name (Legal Business Name): AMANDA L GAGNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 GAFFNEY RD STOP 7440
FT WAINWRIGHT AK
99703-5007
US

IV. Provider business mailing address

1060 GAFFNEY RD STOP 7440
FT WAINWRIGHT AK
99703-5007
US

V. Phone/Fax

Practice location:
  • Phone: 907-361-5301
  • Fax: 907-361-4847
Mailing address:
  • Phone: 907-361-5301
  • Fax: 907-361-4847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number110099
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: