Basic Information
| Provider Information | |||||||||
| NPI: | 1205460813 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LA FAVERS | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | DENISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 RED CLOVER DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450364094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705853854 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10500 MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452424402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138651111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2020 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 019993 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.