Healthcare Provider Details

I. General information

NPI: 1760873491
Provider Name (Legal Business Name): AMANDA KRISTINE NEFSTEAD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2015
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 17TH AVE E SUITE 101
ALEXANDRIA MN
56308-5273
US

IV. Provider business mailing address

111 17TH AVE E SUITE 101
ALEXANDRIA MN
56308-5273
US

V. Phone/Fax

Practice location:
  • Phone: 132-076-2114
  • Fax: 320-762-1935
Mailing address:
  • Phone: 132-076-2114
  • Fax: 320-762-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number664-14
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: