Healthcare Provider Details

I. General information

NPI: 1699091280
Provider Name (Legal Business Name): AMANDA MARIE WEINDL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 07/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR DEPARTMENT OF PEDIATRICS
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

700 W. IRONWOOD DRIVE SUITE 155
COEUR D'ALENE ID
83814-4462
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-7176
  • Fax:
Mailing address:
  • Phone: 208-667-0585
  • Fax: 208-667-0876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number863
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberO-1021
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: