Healthcare Provider Details

I. General information

NPI: 1053859975
Provider Name (Legal Business Name): AMANDA SMITH CLARY CFM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2017
Last Update Date: 02/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 RUIN CREEK RD
HENDERSON NC
27536-5916
US

IV. Provider business mailing address

253 RUIN CREEK RD
HENDERSON NC
27536-5916
US

V. Phone/Fax

Practice location:
  • Phone: 252-492-3404
  • Fax: 252-430-0670
Mailing address:
  • Phone: 252-492-3404
  • Fax: 252-430-0670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License NumberCFM03091
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: