Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 3013222 | KY |
NPI | 1003376609 |
---|---|
Provider Name | Amanda Jane Reid |
First Address | Charlotte, NC 28260-3725 |
Second Address | Cynthiana, KY 41031-3718 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/03/2019 |
Last Update Date | 29/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
K292470 | MEDICARE PTAN (01) | KY |
PENDING | (05) | KY |