Healthcare Provider Details

I. General information

NPI: 1497404040
Provider Name (Legal Business Name): AMANDA HENRY RN, BSN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8298 WADE RD
WARRIOR AL
35180-3016
US

IV. Provider business mailing address

8298 WADE RD
WARRIOR AL
35180-3016
US

V. Phone/Fax

Practice location:
  • Phone: 205-902-1468
  • Fax:
Mailing address:
  • Phone: 205-543-0529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number1-101323
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: