Healthcare Provider Details

I. General information

NPI: 1831673656
Provider Name (Legal Business Name): AMANDA KATHLEEN SHELTON CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA KATHLEEN PHILLIPS CST

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 N 5TH ST
TERRE HAUTE IN
47804-4010
US

IV. Provider business mailing address

1725 N 5TH ST
TERRE HAUTE IN
47804-4010
US

V. Phone/Fax

Practice location:
  • Phone: 812-242-3005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number165941
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: