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NPI Code Detail

MEDICARE: AMANDA NICOLE DALLAS

MEDICARE: AMANDA NICOLE DALLAS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior TechnicianRBT-17-34011CA

General Provider Information

NPI Number : 1871060038
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMANDA NICOLE DALLAS
Provider Business Mailing Address
First Line : PO BOX 33568
Second Line :
City : SAN DIEGO
State : CA
Zip : 92163-3568
Country : US
Telephone Number : 855-223-7123
Fax Number :
Provider Business Practice Location Address
First Line : 2453 GRAND CANAL BLVD STE A
Second Line :
City : STOCKTON
State : CA
Zip : 95207-8138
Country : US
Telephone Number : 855-223-7123
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/25/2018
Last Update Date : 09/05/2024

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Directions to “ AMANDA NICOLE DALLAS ” Practice Location

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