Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 28194541A | IN |
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 71009545A | IN |
NPI | 1033768569 |
---|---|
Provider Name | Amanda Lavender |
First Address | Bedford, IN 47421-3003 |
Second Address | Bloomington, IN 47403-2209 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2019 |
Last Update Date | 09/06/2020 |