Healthcare Provider Details

I. General information

NPI: 1003046616
Provider Name (Legal Business Name): AMANDA LEIGH PERRY DNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 112TH AVE NE
COOPERSTOWN ND
58425-9264
US

IV. Provider business mailing address

665 112TH AVE NE
COOPERSTOWN ND
58425-9264
US

V. Phone/Fax

Practice location:
  • Phone: 601-870-0774
  • Fax: 701-797-3328
Mailing address:
  • Phone: 601-870-0774
  • Fax: 701-797-3328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR41616
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR863756
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: