Healthcare Provider Details

I. General information

NPI: 1316345309
Provider Name (Legal Business Name): AMANDA DELORES ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 KENMORE ST N
WILSON NC
27893-1848
US

IV. Provider business mailing address

2105B FAIRMOUNT AVE APT B
RICHMOND VA
23223-5137
US

V. Phone/Fax

Practice location:
  • Phone: 252-366-3191
  • Fax: 252-399-1193
Mailing address:
  • Phone: 252-366-3191
  • Fax: 252-399-1193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: