Healthcare Provider Details

I. General information

NPI: 1265168348
Provider Name (Legal Business Name): AMANDA JO GLOUDEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E 4TH PLAIN BLVD
VANCOUVER WA
98661-3713
US

IV. Provider business mailing address

2815 E 19TH ST APT S
VANCOUVER WA
98661-4636
US

V. Phone/Fax

Practice location:
  • Phone: 360-397-8246
  • Fax:
Mailing address:
  • Phone: 360-910-5617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCG61340298
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: