Healthcare Provider Details

I. General information

NPI: 1558918326
Provider Name (Legal Business Name): AMANDA ELIZABETH BUNN CPM, LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 SOUTHWAY DR SW APT 25
ROANOKE VA
24014-2264
US

IV. Provider business mailing address

3745 SOUTHWAY DR SW APT 25
ROANOKE VA
24014-2264
US

V. Phone/Fax

Practice location:
  • Phone: 540-855-7913
  • Fax:
Mailing address:
  • Phone: 540-855-7913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number0129000148
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: