=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245612910
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA KNOPP CNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2015
-----------------------------------------------------
Last Update Date | 06/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 539 KELLER LOOP
-----------------------------------------------------
City | WILLIAMSPORT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17701-9394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-492-6398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 539 KELLER LOOP
-----------------------------------------------------
City | WILLIAMSPORT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17701-9394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-492-6398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | T1512641004
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------