=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063185072
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA JEVAHIRIAN NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2021
-----------------------------------------------------
Last Update Date | 10/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25650 OUTER DR
-----------------------------------------------------
City | LINCOLN PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48146-2096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-383-1897
-----------------------------------------------------
Fax | 313-383-6018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4700 SCHAEFER RD STE 340
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48126-3743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-561-5100
-----------------------------------------------------
Fax | 313-565-0309
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704300662NSA210LV
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704300662
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------