Provider Demographics
NPI:1053149278
Name:DILLABOUGH, AMANDA ROSE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:DILLABOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 HIDDEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:DILLWYN
Mailing Address - State:VA
Mailing Address - Zip Code:23936-2372
Mailing Address - Country:US
Mailing Address - Phone:434-390-0142
Mailing Address - Fax:
Practice Address - Street 1:458 HIDDEN VALLEY DR
Practice Address - Street 2:
Practice Address - City:DILLWYN
Practice Address - State:VA
Practice Address - Zip Code:23936-2372
Practice Address - Country:US
Practice Address - Phone:434-390-0142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program