Healthcare Provider Details

I. General information

NPI: 1164082988
Provider Name (Legal Business Name): AMANDA KRANTZ FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 E 5TH ST
COQUILLE OR
97423-1755
US

IV. Provider business mailing address

790 E 5TH ST
COQUILLE OR
97423-1755
US

V. Phone/Fax

Practice location:
  • Phone: 541-396-7295
  • Fax:
Mailing address:
  • Phone: 541-396-7295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201902517RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201908745NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: