Provider Demographics
NPI:1053787283
Name:COMBS, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:COMBS
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 1:202 BEAM LN
Mailing Address - Street 2:
Mailing Address - City:POCOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74902-2463
Mailing Address - Country:US
Mailing Address - Phone:479-926-0332
Mailing Address - Fax:
Practice Address - Street 1:202 BEAM LN
Practice Address - Street 2:
Practice Address - City:POCOLA
Practice Address - State:OK
Practice Address - Zip Code:74902-2463
Practice Address - Country:US
Practice Address - Phone:479-926-0332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004509363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology