Healthcare Provider Details

I. General information

NPI: 1902791676
Provider Name (Legal Business Name): AMANDA ROSE LEE HURST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 WILMINGTON PIKE
CENTERVILLE OH
45459-7004
US

IV. Provider business mailing address

116 LARIAT DR
HARVEST AL
35749-8702
US

V. Phone/Fax

Practice location:
  • Phone: 937-701-7069
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-174204
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: