Basic Information
Provider Information | |||||||||
NPI: | 1164006235 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHN TITUS | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MORGENSTERN | ||||||||
OtherFirstName: | AMANDA | ||||||||
OtherMiddleName: | LEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1230 S 50TH AVE APT 10 | ||||||||
Address2: |   | ||||||||
City: | WAUSAU | ||||||||
State: | WI | ||||||||
PostalCode: | 544018654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7018918216 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10535 HOSPITAL WAY | ||||||||
Address2: |   | ||||||||
City: | MATHER | ||||||||
State: | CA | ||||||||
PostalCode: | 956554200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9168437000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2021 | ||||||||
LastUpdateDate: | 05/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | R36608 | ND | Y |   | Nursing Service Providers | Registered Nurse | General Practice |
No ID Information.