=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326852245
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. AMANDA ANNE VAN AUKEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2025
-----------------------------------------------------
Last Update Date | 02/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 159 W 1ST ST
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13126-2045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-342-9575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8740 N ENTRY RD
-----------------------------------------------------
City | BALDWINSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13027-1534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-263-8303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 1807015241
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 1806960241
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------