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General NPI Number Information
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NPI Number | 1235486952
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Entity Type | Individual
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Provider Name | AMANDA NICOLE BREEDLOVE PNP
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Gender | Female
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Dates
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Enumeration Date | 08/13/2012
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Last Update Date | 02/28/2013
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Provider Practice Location Address
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Address Line | 1203 SMIZER MILL RD SUITE 100
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City | FENTON
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State | MO
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Zip | 63026-3483
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Country | US
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Telephone | 636-717-1414
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Fax |
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Provider Business Mailing Address
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Address Line | 1203 SMIZER MILL RD
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City | FENTON
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State | MO
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Zip | 63026-3483
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Country | US
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Telephone | 636-717-1414
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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 | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 2012026927
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License Number State | MO
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