Provider Demographics
NPI:1053999383
Name:LOOSE, AMANDA LYNN (BS, QIDP, QMHP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:LOOSE
Suffix:
Gender:F
Credentials:BS, QIDP, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 KELLY ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651-2530
Mailing Address - Country:US
Mailing Address - Phone:989-859-2790
Mailing Address - Fax:
Practice Address - Street 1:511 GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-9251
Practice Address - Country:US
Practice Address - Phone:989-345-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker