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General NPI Number Information
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NPI Number | 1114300332
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Entity Type | Individual
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Provider Name | AMANDA RYAN
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Gender | Female
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Dates
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Enumeration Date | 07/07/2015
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Last Update Date | 07/07/2015
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Provider Practice Location Address
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Address Line | 2851 UNIVERSITY AVE
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City | GREEN BAY
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State | WI
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Zip | 54311-5855
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Country | US
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Telephone | 716-440-4117
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Fax |
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Provider Business Mailing Address
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Address Line | 97 PROMENADE LN
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City | WILLIAMSVILLE
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State | NY
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Zip | 14221-1924
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Country | US
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Telephone | 716-440-4117
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QV0200X
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Taxonomy Name | VA Clinic/Center
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License Number | 060491
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License Number State | NY
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