Basic Information
| Provider Information | |||||||||
| NPI: | 1942549506 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAGNON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1060 GAFFNEY RD STOP 7440 | ||||||||
| Address2: | |||||||||
| City: | FT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997035007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073615301 | ||||||||
| FaxNumber: | 9073614847 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 GAFFNEY RD STOP 7440 | ||||||||
| Address2: | |||||||||
| City: | FT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997035007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073615301 | ||||||||
| FaxNumber: | 9073614847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2013 | ||||||||
| LastUpdateDate: | 02/01/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WX0106X | 110099 | KS | Y | Nursing Service Providers | Registered Nurse | Occupational Health |
No ID Information.