Healthcare Provider Details

I. General information

NPI: 1316337348
Provider Name (Legal Business Name): AMANDA CHRISTINE PACKO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 BELMONT AVE
YOUNGSTOWN OH
44504-1006
US

IV. Provider business mailing address

4135 BOARDMAN CANFIELD RD STE 101
CANFIELD OH
44406-9803
US

V. Phone/Fax

Practice location:
  • Phone: 330-480-3658
  • Fax: 330-480-3439
Mailing address:
  • Phone: 330-286-5330
  • Fax: 330-286-5396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN342265COA1
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.17032
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: