Healthcare Provider Details

I. General information

NPI: 1093932212
Provider Name (Legal Business Name): AMANDA DIAMOND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 1ST AVE S
FARGO ND
58103-1802
US

IV. Provider business mailing address

700 1ST AVE S
FARGO ND
58103-1802
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-4036
  • Fax: 701-234-4160
Mailing address:
  • Phone: 701-234-4036
  • Fax: 701-234-4160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberLP00224
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number10863
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: