Healthcare Provider Details

I. General information

NPI: 1144115833
Provider Name (Legal Business Name): AMANDA ROSE YEAZEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 N 3RD ST
GOSHEN IN
46528-7100
US

IV. Provider business mailing address

123 OAK RD
PLYMOUTH IN
46563-9751
US

V. Phone/Fax

Practice location:
  • Phone: 574-534-3300
  • Fax:
Mailing address:
  • Phone: 574-780-1673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number28251364A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: