Healthcare Provider Details

I. General information

NPI: 1528311974
Provider Name (Legal Business Name): AMANDA YETTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2012
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2063 HEMSTREET RD
EAST AURORA NY
14052-9689
US

IV. Provider business mailing address

2063 HEMSTREET RD
EAST AURORA NY
14052-9689
US

V. Phone/Fax

Practice location:
  • Phone: 716-715-2055
  • Fax:
Mailing address:
  • Phone: 716-715-2055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number301705
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: