Healthcare Provider Details

I. General information

NPI: 1891466843
Provider Name (Legal Business Name): AMANDA ROBERTS PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 SOUTHLAND AVE
KOKOMO IN
46902-3689
US

IV. Provider business mailing address

3900 SOUTHLAND AVE
KOKOMO IN
46902-3689
US

V. Phone/Fax

Practice location:
  • Phone: 317-876-3699
  • Fax: 765-453-3773
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71011683B
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71011683A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: