Healthcare Provider Details

I. General information

NPI: 1962595405
Provider Name (Legal Business Name): AMANDA JEAN BARTON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 N ROLAND ST
MC BAIN MI
49657-9683
US

IV. Provider business mailing address

520 COBB ST
CADILLAC MI
49601-2588
US

V. Phone/Fax

Practice location:
  • Phone: 231-825-2643
  • Fax: 231-825-0161
Mailing address:
  • Phone: 231-876-6527
  • Fax: 231-876-6519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704216141
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number4704216141
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: