Healthcare Provider Details

I. General information

NPI: 1841080694
Provider Name (Legal Business Name): AMANDA LODGE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2025
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

579 BELT CREEK RD
BELT MT
59412-8007
US

IV. Provider business mailing address

579 BELT CREEK RD
BELT MT
59412-8007
US

V. Phone/Fax

Practice location:
  • Phone: 406-899-1630
  • Fax:
Mailing address:
  • Phone: 406-899-1630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number719901
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberNUR-RN-LIC-146531
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: