Healthcare Provider Details

I. General information

NPI: 1700407236
Provider Name (Legal Business Name): AMANDA MARIE HUTTIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 TALON CT
TAYLORS SC
29687-4258
US

IV. Provider business mailing address

214 TALON CT
TAYLORS SC
29687-4258
US

V. Phone/Fax

Practice location:
  • Phone: 567-242-3020
  • Fax:
Mailing address:
  • Phone: 567-242-3020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number246542
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: