Healthcare Provider Details

I. General information

NPI: 1164049698
Provider Name (Legal Business Name): AMANDA J BEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 TERRE VERTE CT
SAINT CHARLES MO
63304-1217
US

IV. Provider business mailing address

23 TERRE VERTE CT
SAINT CHARLES MO
63304-1217
US

V. Phone/Fax

Practice location:
  • Phone: 716-228-0524
  • Fax:
Mailing address:
  • Phone: 716-228-0524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2020003743
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: