=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144665480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA RAE PLOCKI LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2013
-----------------------------------------------------
Last Update Date | 05/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6847 N CHESTNUT ST
-----------------------------------------------------
City | RAVENNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44266-3929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-968-7438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3232 RAUSCH AVE
-----------------------------------------------------
City | RAVENNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44266-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-968-7438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | PN.152642-M-IV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Registered Nurse
-----------------------------------------------------
License Number | RN.433124
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------