Healthcare Provider Details

I. General information

NPI: 1740707967
Provider Name (Legal Business Name): AMANDA SUE MACKLIN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 03/29/2025
Certification Date: 03/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 N FAIRVIEW DR # 256
TACOMA WA
98406-1015
US

IV. Provider business mailing address

426 SW HAYWORTH DR UNIT 203
PORT ORCHARD WA
98367-5015
US

V. Phone/Fax

Practice location:
  • Phone: 253-777-1423
  • Fax:
Mailing address:
  • Phone: 253-313-2284
  • Fax: 253-276-6907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberN360791741
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP60784445
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60784445
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: