Healthcare Provider Details

I. General information

NPI: 1467223685
Provider Name (Legal Business Name): AMANDA SOUDOM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 HILLCREST DR
BRANDENBURG KY
40108-1296
US

IV. Provider business mailing address

534 HILLCREST DR
BRANDENBURG KY
40108-1296
US

V. Phone/Fax

Practice location:
  • Phone: 270-422-5000
  • Fax: 270-422-5052
Mailing address:
  • Phone: 270-422-5000
  • Fax: 270-422-5052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4015068
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: