Healthcare Provider Details

I. General information

NPI: 1104009612
Provider Name (Legal Business Name): AMANDA KREIENHEDER I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3315 8TH ST
LEWISTON ID
83501-4966
US

IV. Provider business mailing address

4690 STAR MEADOW RD
WHITEFISH MT
59937-8371
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-9543
  • Fax:
Mailing address:
  • Phone: 406-253-3441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SR0400X
TaxonomyRehabilitation Clinical Nurse Specialist
License NumberPTA-394
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: