=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972909745
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA VALIENTE CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2014
-----------------------------------------------------
Last Update Date | 11/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 7TH ST SE
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35601-3337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-341-2545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17519 ZEHNER RD
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35611-8331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-444-0560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 1-111909
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------