1164006235 NPI number — MRS. AMANDA LEE JOHN TITUS RN

Table of content: MRS. AMANDA LEE JOHN TITUS RN (NPI 1164006235)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164006235 NPI number — MRS. AMANDA LEE JOHN TITUS RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHN TITUS
Provider First Name:
AMANDA
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MORGENSTERN
Provider Other First Name:
AMANDA
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164006235
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1230 S 50TH AVE APT 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUSAU
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54401-8654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-891-8216
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10535 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATHER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95655-4200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-843-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/05/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WG0000X , with the licence number:  R36608 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)